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DISEASES PECULIAR TO WOMEN.

Dublin : Printed by Gunn and Cameron, Fleet street

CLINICAL LECTURES

DISEASES PECULIAR • TO WOMEN.

LOMBE ATTHILL, M.D., Univ. Dubl.,

PRESIDENT OF THE DUBLIN OBSTETRICAL SOCIETY, MASTER OF THE
ROTUNDA HOSPITAL, AND CONSULTING OBSTETRIC SURGEON
TO THE ADELAIDE HOSPITAL,

DUBLIN.

dfmtrtlj etrittan, HcluiRtr anH enlanjrU.

DUBLIN:

FANNIN and CO., GRAFTON STREET.
LONDON: LONGMANS, GREEN & GO.
EDINBURGH: MACLACHLAN and STEWART.

MDCCCLXX V I.

'■

A I /

PREFACE TO THE FOURTH EDITION.

After much consideration I have decided on presenting this
Edition of my Lectures to the profession in an unaltered
form. A large edition has gone out of print in eighteen
months, and while gratified, as every author must be, at
such a result, I am deeply impressed with the responsibility
thereby entailed.

It is impossible that a fourth edition of any Medical work
can be reached without its influencing to a considerable
extent the management of the diseases of which it treats,
and the author should weigh well not alone the views and

statements he puts forward, but also the omissions he
makes.

These Lectures have been characterized by a reviewer in
the Edinburgh Medical Journal as “a very imperfect com-
pendium of the diseases of women.” This charge would
have some truth in it had the volume been put forward as a
complete treatise on gynaecology. Such it did not profess
to be, but still it affords to students and practitioners infor-
mation on all the diseases peculiar to women” which fairly

PREFACE.

come within the limits of a work on these subjects. The
criticism is not, however, devoid of weight, and I have been
urged, by “ enlarging the scope” of this volume, at once to
render for the future such a criticism impossible, enhance
my reputation as an author, and add to the value of the

work.

After much hesitation I have decided against following the

advice thus in good faith tendered.

By “ enlarging the scope” of the work is meant the dis-
cussing in extenso not alone the pathology and treatment of
uterine and ovarian disease, but also the describing in
detail all the numerous operations now falling within the
province of the obstetric surgeon, including ovariotomy
and that for the cure of vesico vaginal fistula. The task
would not indeed be a very serious one, for my difficulty
has been, while omitting all that was superfluous, to con-
vey in language as clear and concise as possible all that
seemed to me to be essential for my purpose. But while
admitting the force of the first two reasons, I much doubt
if by “ enlarging the scope” of the volume I would add to

its usefulness.

The object I had in view, in which I am gratified by
feeling I have in some degree succeeded, was not to supply
practitioners and students with information already within
their reach, in recognized manuals of surgery, but to furnish
them, in the limits of a moderate-sized volume, with such an
account of the Diseases Peculiar to Women, brought up to
the standard of the most recent period, and verified by my

PREFACE.

vii

personal experience, as would meet their wants, and tend
to the more general diffusion of a knowledge of these com-
mon, but unfortunately much-neglected affections.

I have endeavoured, however, in the present Edition to
render the volume more worthy of the favourable reception
accorded to it by a careful revision, and by the addition in
many places of new matter, suggested by the experience
obtained in the great field of observation afforded me in this
Hospital.

Rotunda Hospital, Dublin,
1st November, 1S76.

LOMBE ATTHILL.

PREFACE TO THE FIRST EDITION.

The following pages contain the substance of the Lectures
addressed to the class attending the Adelaide Hospital during
the past year. They were not delivered in any regular order,
but as cases suitable for illustrating the various forms of
Uterine Disease presented themselves. Nor had I, at tho
time, any intention of publishing them. Subsequently I
was induced to do so, influenced mainly by the desire ex-
pressed by some of the members of the class, to have for
reference a concise summary of the practice they had seen
carried out in the hospital.

„ Another reason also influenced me. In my capacity of
Examiner, first in the Queen’s University, and subsequently
the ColleSe of Physicians, I was much struck by the utter
ignorance evinced by the great majority of candidates on the
subject of “ Diseases of Women.” Nor was this ignorance
confined to the evidently idle men. Thus, even those whose
answering „„ all other subjects proved that they had made
good use of their time, were frequently unable to state cor-
rectly a single cause on which such a common and important
symptom as Menorrhagia might depend; and consequently
showed themselves incapable of treating cases in which it
might occur. These gentlemen, when remonstrated with

PREFACE.

invariably alleged as an excuse, that the numerous subjects
they were required to study, precluded their reading the ad-
mirable, but somewhat voluminous, works existing on uterine
and ovarian affections, and which were the only ones attain-
able. I trust that the following Lectures, which are devoted
to the consideration of the subject solely in its clinical aspect,
will be found to contain a tolerably full account of the pre-
sent method of treating the “ Diseases Peculiar to Women,”
and will prove an incentive to the study ot this impoitant
branch of our profession.

In conclusion, I have only to add, that 1 do not lay claim
to originality in the views put forward in these Lectin es. 1
have simply endeavoured in my practice to keep pace with
the recent advances which have been made, in the medical
and surgical treatment of the class of cases which have been
placed under my care, and to which I have paid special
attention for a period of nearly twenty years. Nor have I
advocated any treatment, the efficiency of which I have not

fully tested.

LOMBE ATTHILL.

II Ul‘ PER MERRION -STREET, DUBLIX,

1st Oct., 1371.

CONTENTS.

LECTURE I.

Introductory— Mode of examining patients— Use of speculum—
Uterine sound

LECTURE II.

Leucorrhma— Its characteristics, sources, causes and treatment —
Vaginitis— Vaginismus ....

LECTURE III.

Menstruation— Amenorrhcea— Causes of— Treatment of various
lorms ot — Use of galvanic stem pessary

LECTURE IV.

Dysmenorrhcea— Varieties of— Cause of pain in— Treatment of .

LECTURE V.

Menorrhagia— Causes of— Subinvolution— Treatment of — Ute-
rine porte-caustique — Plugging vagina

LECTURE VI.

Menorrhagia (continued) — Granular ulceration of cervix— Gra-
nular condition of cavity— Mode of dilating cervix— Sea-
tangle tents — Use of nitric acid — Curette

LECTURE VII.

Polypus— Mucous, cystic and fibrous— Operations for removal of
-Steel. wire -Author’s Ecraseur -Fibrinous and placental

LECTURE VIII.

Spontaneous cure'63 ^rea^meut~l*llJ,lence of pregnancy

117

XI 1

CONTENTS.

22S

LECTURE IX.

PAG JE

Inflammation of the Cervix Uteri — Ulceration of Treatment of
by local depletion, nitric acid, and Styptic Colloid— Pelvic

cellulitis — Pelvic lnematocele 150

LECTURE X.

Chronic Inflammation of Cervix — Induration of Treatment by
potassa fusa and by local depletion — Endo-metritis Endo-

cervicitis 1 ^

LECTURE XL

Displacements of the Uterus — Retroflexion Its causes, symp-
toms and treatment— Hodge’s pessary— Value of local blood-
letting—Anteflexion — Prolapsus uteri — Retroversion . . lJo

LECTURE XII.

Enlargements of the Uterus— Frequency of— Causes of, considered
with reference to diagnosis .

LECTURE XIII.

Cancer— Varieties met with— Medullary and Epithelial
tom — Cauliflower excrescence — Amputation of

General Treatment

LECTURE XIV.

Ovarian cystic disease-Pathology — Unilocular, multilocular
and dermoid — Varieties — Symptoms Diagnosis.

LECTURE XV.

Ovarian disease ( continued) — Effect on duration of life O'ai io
tomy— Statistics of— Tapping cyst-injection of cyst-ln-
flammation of the ovary •

LECTURE XVI.

Uterine therapeutics— External applications— Hot and cold hip-
baths—Use of Chapman’s spinal hot water and ice bags
Wet bandages— Blisters— Iodine •

LECTURE XVII.

Uterine therapeutics (continued)— Applications to the va^na
and uterus— Vaginal injections— intra-utenne applications
— Medicinal treatment

-Symp-
Cervix —

240

2S7

296

LIST OF ILLUSTRATIONS.

8.
9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.
21.
22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

Bi-valve Speculum .
Four-bladed Speculum .
Duck-bill Speculum .

Mode of Introducing Sound
Galvanic Stem Pessary
Priestly’s Dilator .
Savage’s Metrotome
Barnes’ Scissors
Greenhalgli’s Metrotome .

Greenhalgh’s Expanding Intra-uterine Stem
Intra-uterine Porte-caustique .

Polypus Sea-tangle in situ, to effect Diktat
Vulsellum
Wire Ecraseur

Eeraseur applied for removal of Polypu
Dr. Atthill’s Ecraseur
Fibrous tumour with Double Attachment
Uterine Out-growth or Polypus
Uterine Fibrous tumour .

Extra-uterine Fibro-cystic Tumour .
Intra-mural Fibroid of Cervix
Intra-mural Fibrous Tumour
Hall’s Knife for Puncturing Cervix .
Retroversion of Uterus
Retroflexion of Uterus
Hodge’s Pessary
Hodge’s Pessary in situ .

Greenhalgli’s Spring Pessaries
Complete Prolapse of Uterus
Apparatus for Vaginal Injections .'

Playfair’s Probes

Author’s Cannula for Intra-uterine Medicath

PAGE

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CLINICAL LECTURES

DISEASES PECULIAR TC WOMEN.

LECTURE I.

Introductory Remarks— Mode of Examining Patients— Use of
Speculum— F 'ergusson’s— Bi-valve— Duck-bill — Uterine
Sound— Method of Introduction— Information to be Ob-
tained from its Use— Bi-manual Method of Examination.

Gentlemen— It is of course essential to the right treat-

ment of any disease, that the condition of the affected orcrfl
should be carefully and scientifically investigated. To asse:

To assert
;n coming:

organ

ithout previously ascertaining the con-
viscera? Yet many do not hesitate to

DISEASES OF WOMEN.

undertake the treatment of a case in which hsemorrhage fiom
the uterus is present, without having the least idea whether
the haemorrhage depends on the existence of granular ulcera-
tion of the os and cervix uteri, on the presence of a polypus,
of cancer, of that condition known as sub-involution of the
uterus, or on some other less easily demonstrable causes. I
therefore unhesitatingly lay it down as a rule, that m all cases
presenting symptoms of uterine disease, a careful examina-
tion of the pelvic viscera should be made. But let me at
the same time earnestly impress on you the duty of con-
ducting such an examination in a mode as little irksome as
possible to the patient, and with all possible delicacj .

Now, in nearly every case of uterine or vaginal disease, we
require the aid of both touch and sight to enable us to arrive
at a correct conclusion as to the condition of the affected
organs. To use the speculum without a previous examina-
tion by the finger and hand, is not only wrong, but it also
fails to convey to us anything like an accurate knowledge of
the case. Thus a patient suffers from leucorrhoca with peh ic
pain, and pains in the thigh. You make an examination
with the speculum, and finding the os uteri healthy, may
hastily come to the conclusion that no abnormal condition
of the genital organs exists, and perhaps assure the patient
that the womb is healthy. But nevertheless she is dissatis-
fied, for her sufferings continue, and by and by she consults
another practitioner, who detects the existence of a rctro-
flected or anteflected uterus— a condition which an ocular
inspection of the os uteri failed to recognize. I could easily
multiply examples, but let this one suffice to impress you with
the necessity of making a manual examination before using
the speculum.

In speaking of a manual examination, I mean more than
a digital examination of the vagina. 1 include also under

DIGITAL EXAMINATION.

that term the investigation of the pelvic viscera through the
abdominal walls, and, if the symptoms seem to demand it,
through the rectum also. I shall make a few remarks on
the mode of conducting these investigations.

biist, then, as to the ordinary digital examination of the
vagina and uterus. The patient is to be placed on her left
side, with the head low and bent well forward, taking care,
too, that she does not rest upon her elbow; the knees should
be well drawn up, and the hips pushed out to the edge of the
couch. These preliminaries effected, the index finger, pre-
viously well greased* should be introduced slowly upwards,
m the axis of the outlet of the pelvis, the tip of the finger
being kept in contact with the posterior wall of the vagina.
By adopting this course the finger reaches the posterior cul
de sac of the vagina, and by carrying it from this point round
the cervix uteri, we are enabled at once to ascertain the con-
dition of the lower segment of the uterus. Thus we learn
whether it be movable or fixed, whether it be of the normal
size and shape, or, on the other hand, elongated or
hypertrophied. Then, by drawing the finger down aW its
surface you reach the os uteri and discover its state; whether
it be patulous, with everted lips, or small and contracted
VVlnle thus engaged in investigating the condition of the
uterus, you should not fail to attend to that of the vagina
and satisfy yourself whether it be of the natural tempera-
ture and moisture, or unduly hot and dry. But there is
more yet to be ascertained before you have gained all the
information possible from a digital examination— the position
of the uterus itself is to be made out, for the organ may be

For this purpose a compound of Purified Snft n
one part, and Carbolic Acid five r tl! Soap, three parts; Glycerine.

washes off easily, is a deodoriser and dilinfcchnt' answers admirably. It
or any other article on which it falls, as oil and Jease do Cl°thes

n 2

DISEASES OF WOMEN.

retroflected or anteflected, or possibly, under certain circum-
stances, completely rctroverted.

As a rule, you should not be able to feel the body of the
unimpregnated uterus through the posterior cul de sac of the
vagina. If therefore on sweeping the finger round the cervix
posteriorly, you feel a firm globular mass above, you can at
once pronounce that the organ is in an abnormal condition.
Then immediately follows the question, which you are called
upon to solve; namely, on what does this enlargement de-
pend? But I must defer the consideration of this question
to a future lecture; for a mere digital examination, though
of importance, is frequently insufficient to enable us to decide
this point; aud in a large number of cases you must not
remain content with it, or you will fall into grave errors. To
make your examination complete, you must have recourse to
the use both of the speculum and of the uterine sound. I
name them in the order in which, as a rule, they should be
used.

You see on the table three kinds of speculums. All
of them are admirable instruments, and, as I am about to
explain to you, each possesses certain advantages which
the other wants, and certain disadvantages which renders
the use sometimes of one, and sometimes of another,
preferable. It is, therefore, essential that you should be
acquainted with the respective merits of each. There are,
no doubt, numerous other kinds ; but, for ordinary purposes
these are sufficient, and for general use I without hesita-
tion recommend the one known as Fergussons. It is, as
you are aware, a glass cylinder silvered externally. This
again is protected by a layer of gutta percha, which answers
the double purpose of affording a very smooth surface, aud
serving as a protection to the vagina should the glass by any
mischance crack or break. Through a full-sized one of these

bi-valve speculum.

speculums you can see the parts very distinctly; it also
possesses this great advantage, that it is uninjured by the
action of acids, a class of remedial agents which are frequently
used m the treatment of uterine disease. It is not, however
so easily introduced as either of the other speculums which
I exhibit. . If, therefore, the vagina be narrow, or if much
inflammation be present, the attempt to use a full-sized one
mil give so much pain that you will have to desist, and
should you with the view of avoiding this, have recourse to
a smaller one, you will find much difficulty in bringing the
os into view; even when you succeed in doing soothe
.portion of the cervix exposed to view will be of such limited
extent as often to afford but little information. Still the
number of cases in which it is inapplicable will prove to be
comparatively few. When, from the narrowness of the orifice
of the vagina, or from the amount of inflammation present
you find Fergusson’s speculum to be unsuitable, I recommend

you to make use of a plated bi-valve, such a one as this
(big. 1).

Fig. 1.

It is very easily introduced, but does not reflect the light
neai y so well as the glass one does, and moreover the lateral

DISEASES OF WOMEN.

folds of the vagina fall, to a considerable degree, into the
space between the blades when they are expanded, and in-
tercept your view. To remedy the latter objection, Dr. Graily
Hewitt has introduced a four-bladed speculum (Fig. 2),

Fig.

which in several respects is superior to any other expanding
speculum.

This speculum, which, from its shape, is known as the
duck-bill speculum (Fig 3), affords one advantage which
neither of the others possess; namely, it permits you to see
the os uteri, and at the same time to touch it— a matter
of the greatest importance in many cases. A\ e there-
fore use it when introducing sea-tangle or sponge tents
into the cervix uteri; or when, having withdrawn these,
we proceed to examine the condition of, or to make applica-
tions to, the canal of the cervix or body of the uterus, an
also in the case of all operations about the vagina or uterus-
Its disadvantages are that the forcible drawing back of the
perineum, which is necessary to permit the os uteri to be
seen, causes pain; while if the instrument be not held veiy
steady, the os slips out of view. Secondly, that it is a >so-
lutely necessary to have an assistant present to take charge

INTRODUCTION OF SPECULUM.

of it ; and thirdly, that difficulty is often experienced in
keeping the anterior wall of the vagina from intercepting
the view, unless, indeed, you seize the os with a hook or
vulsellum — the reasons for, and the mode of, doing which, I
shall explain on a future occasion.

Fig. 3.

I shall now give a few directions as to the mode of
introducing the speculum; for, if the instrument is used in a
bungling, unhandy way, not only will your patient be caused
much unnecessary pain, but you will also most likely leave
an unfavourable impression on her mind as to your skill:
I therefore feel that I am not wasting time in dwelling on
these minutiae. First, then, you should dip your speculum
into warm water to bring it up to the temperature of the
body, and oil it; then the patient lying on the left side with
her hips well out, you should, with the index and middle
finger of the left hand, raise and draw up the right labium
and nympha, while with the thumb and index finger of the
right hand you hold the speculum, and bring its points to
the orifice of the vagina. You should at the same time,
with the middle finger of that hand, depress the soft parts
on the left side; for if this be not done, and if the labia or

DISEASES OF WOMEN.

nymph eg be turned in before the edge of the speculum, the
patient will be caused much unnecessary pain which a little
care would have obviated.

When once the point of the speculum has fairly entered
within the vagina, its further introduction is a matter of no
difficulty; but still it is very possible for a person inexpe-
rienced in its use to fail in bringing the os uteri into view;
therefore, you should be careful to keep the point of the
instrument pressed well back against the posterior wall of
the vagina, for the os uteri should look downward and back-
ward, so that by keeping the point of the instrument in the
direction I have indicated, the os should without difficulty
come into view. If this be not the case the speculum should
be withdrawn a little way, and its direction slightly altered,
when the desired object will most likely be attained. The
foregoing directions hold equally good whether you use
Fergusson’s, or the expanding speculum; for though the
latter on account of its shape, is introduced with greater
facility, yet it is not easier with it to bring the os into view;

indeed the reverse is the case.

The duck-bill speculum requires special directions for its
nse. The following are those given by the inventor, Dr.
Marion Sims, and should be carefully attended to whenever
this speculum is used — “The thighs are flexed at right
angles with the pelvis, the patient lying in a semi-prone
position on her left side, her left hand being drawn back-
wards under her, and kept in that position ; the chest rotated
forward, bringing the sternum very nearly in contact with
the table or couch, the head resting on the parietal bone ;
the head must not be flexed on the sternum nor the right
shoulder elevated ; the patient is thus rolled over on the
front, making it a left lateral semi-prone position. The
nurse or assistant at her back, pulls up the right side of the

VAGINAL EXAMINATION.

nates with the left hand, while the surgeon introduces the
speculum, elevates the perineum, and gives the instrument
into the hand of the assistant, who holds it firmly in the
desired position. These directions are admirable, and
should be strictly attended to.

When with either speculum you have exposed the os uteri,
you are able to judge of its state. You see first of all what
may be the condition of the lips j if they are covered with
healthy mucous membrane, and present the normal light
mother-o’-pearl coloured appearance, or whether they be
congested, abraded, or in a state of granular ulceration,
bleeding on the slightest touch; you see also whether the os
be a small opening, free from discharge, or whether it be
patulous, and plugged with a string of thick, glairy mucus,
the sure indication of an unhealthy condition of the cervical
canal. Then, while withdrawing your speculum, you have an
opportunity of satisfying yourself as to the condition of the
vaginal mucous membrane; thus by touch and sight you are
enabled to pronounce with positive certainty as to the state
of the os, of the lower segment of the cervix uteri, and of the
vagina ; but, should you stop here, you will in many cases
have failed in your duty. Many a sufferer has been told,
after having submitted to such an examination, that the
womb was perfectly healthy, because the os and cervix
appeared to be free from disease, and has consequently been
looked upon as a complaining hypochondriac by her friends,
while m reality she was a suffering invalid— the physician
avmg failed to detect the actual ailment, either because he
omitted to carry his investigation further, or because he was
ignorant how to do so. For myself I lay down the following
rule, which I advise you to pursue, in the investigation of all
cases of uterine disease which come under your observa-
tion:—1st. To make a digital examination of the vagina and

DISEASES OF WOMEN.

cervix uteri ; 2nd. If that fails in satisfying me as to the cause
of the patient’s suffering, then to use the speculum ; and 3rd.

If still in doubt,, to introduce the uterine sound, unless its
use be clearly contra-indicated.

You are aware that the sound is an instrument of com-
paratively recent invention ; still it is surprising how little it is
used, and how few appreciate its merits. I look on it as
one of the most useful, and at the same time, if carefully and
judiciously handled, safest of obstetric instruments. In my
own practice I am indebted to it for most important infoima
tion which could not have been obtained by any other means,
and this too without having ever known it to produce the
most trifling injury. Doubtless I am aware, that if roughly
and unskilfully handled, or used in an improper case, the most
serious consequences may follow its introduction; but the
same may be said of the catheter, or indeed of any other in-
strument requiring skill. I again repeat, that if carefully used
and skilfully handled, it is a harmless instrument, and may be

employed with perfect safety.

Before explaining the mode of introducing the sound,
I wish to call your attention to the instrument itself. It is,
as you see, a metallic staff, not unlike the sound used by
surgeons for examining the bladder in the male. 1 he best
are made of copper, plated. The advantage which they possess
is that you are able to bend them at pleasure; a matter of no
small importance, as you are frequently obliged to alter the
curve when flexions of the uterus exist. At a distance of
two and a quarter inches from the extremity of the instrument
there is a little knob, which marks the depth to which it should
usually penetrate into the uterine cavity; and at this point
you observe the instrument is curved, so that it may pass in
a direction corresponding with the axis of the uterine cavity.
The entire length of the instrument is marked at intervals ot

INTRODUCTION OF SOUND. JJ

an inch by notches, which enable you at once to decide to
what depth the instrument lias penetrated; for when with-
drawing it, if you keep the point of your finger on the notch
nearest to the os, you can with the aid of the figures marked

on the handle, see at a glance what the depth of the uterine
cavity may be.

Fig. 4.

J10DE or Introducing Sound.

’ . not a mattei of any great difficulty to introduce the
sound into the cavity of the uterus; still it requires tact and
P < c ice, j ust as the use of the catheter does. The following

. uec 10ns Wl11 aid Jon in obtaining the requisite skill:— Hold-
ing the sound in the left hand, I recommend you to introduce
the index finger of the right into the vagina, and keeping its
tip m close contact with the os uteri, guide the point of

DISEASES OF WOMEN'.

the sound up to the os, slipping it along the inner surface of
the finger, the concavity of the instrument being turned to-
wards the rectum (Fig. 4).

A little manipulation and gentle pressure will now make
it enter the canal of the cervix. This being fairly accom-
plished, a fact you cau always be sure of because your finger
is still in contact with the os, you are to rotate the handle
of the sound, a manoeuvre exactly similar to that pi-actised
by surgeons when introducing the catheter in the male, and
termed the “ tour de maitre.” This has the effect of chang-
ing the direction of the point of the instrument, which will
now look upwards and forwards in the direction of the
axis of the uterus; steady but very gentle pressure should
now be made, and the point will, in general, pass on with-
out difficulty till it reach the os internum; here some slight
obstruction is met with. This, if it occurs, should be
overcome by gentle continuous pressure ; force must not on
any account be used, lest injury be done to the uterine
walls. As the point of the instrument passes through the
os internum, the patient nearly always complains of pain
and sometimes of nausea; but, as a rule, this subsides in a
few minutes. When it is severe and lasts, as it sometimes
does for some hours, metritis or endo-meti’itis will be found to
exist, and I have on one or two occasions kuown a patient to
feel faint ; this feeling, too, soon passed off, and was never
sufficient to prevent my finishing the examination; but it is
well to tell your patient before you introduce the sound, that
she may expect some pain, or at least a feeling of discomfort,
similar to that experienced at the approach of a menstrual
period.

In some instances an obstruction to the introduction of
the instrument is met with low down in the cervical canal.
This is not due to any contraction, but to the point of the

UTERINE SOUND.

sound becoming entangled in a fold of the mucous membrane,
which in this portion of the iutra-uterine canal is not smooth
but plaited. Should this occur you must withdraw the point
a little, and altering its direction somewhat, again press it
•onward. This difficulty is more likely to occur when the os
uteri is patulous, and the cervical canal relaxed from the
■effects of disease, than when it is in a healthy condition;
but a little patience and careful manipulation will always
overcome these obstructions. I have dwelt at some length
on the mode of introducing the sound, because the difficulties
of the operation have been much exaggerated, and I am satis-
fied that they are mainly due to want of skill on the part of
the operator.

The method of using the sound which I have described
is that which I always adopt; but there are other modes
doubtless equally as good. Thus Dr. Graily Hewitt, follow-
ing the plau recommended by Sir J. Simpson, introduces
the index finger of the left hand, guiding the sound along
it up to the os uteri : while Dr. West recommends intro-
ducing two fingers of that hand for the purpose, the instru-
ment being held in the right hand. But whichever method
you adopt, you will speedily with a little practice become
adepts, only remember, never use force; better far that you
should never use the instrument, than that you should run
the risk of injuring the uterus, and perhaps cause a fatal
result, in doing by force what should only be accomplished
by tact.

But you will frequently meet with cases in which the use
of the sound is entirely forbidden. Thus, if there be any
possibility of pregnancy existing, it would be most improper
to introduce it, and wait until you are satisfied on this
point. In cases of cancer, too, and as a rule, during an
attack of any form of acute inflammation, your own judg-

DISEASES OF WOMEN.

ment will warn you against it. But with such exceptions as
these, I can confidently recommend the sound as a safe
and useful instrument. So high is my opinion of the
value of the information to be obtained by the judicious use
of the uterine sound, that I make it a rule to introduce it in
all doubtful cases, unless its use is contra-indicated by the
possible existence of pregnancy, or some equally valid cause;
and I am satisfied that this will, at no distant time be re-
cognized by all well informed obstetric practitioners as the
established rule.

Now, as to the information to be obtained from its use.
We learn three things, which it would be impossible to ascer-
tain by any other means. First, we determine with positive
certainty what the depth of the cavity of the uterus is. If
the sound pass beyond the nodule at the curve of the instru-
ment, we know that the cavity is unduly elongated, and we
can measure accurately the extent to which it is elongated.
Secondlv, we ascertain the position of the uterus, and detei-
m in e whether it be in its normal position, 01 flexed antciiorlj
or posteriorly. Lastly, we learn whether the organ is fixed
or movable, free, or attached to any tumour, which we may
detect exists in the pelvis. rl his is a mattei of the greatest
moment; for when we come to determine the all-important
question as to the nature of some abdominal tumour, the
sound, and the sound alone, enables us to decide whether
the uterus is engaged in that tumour or not.

But our means of obtaining information are not yet ex-
hausted. Our examination hitherto has been carried on
through the vagina. e have ascertained what the con-
dition of the os uteri is. Wo have measured the depth of
the intra-uterine canal with our sound. "\\ e are satisfied
that the uterus has retained its natural position, or is dis-
placed. But we know nothing of the condition of the exter-

BI-MANUAL EXAMINATION.

nal ox’ peritoneal .surface of that organ. A fibrous tumour, for
instance, of any conceivable size, may be developed from any
portion of the uterine wall, and yet the examination I have
hitherto described may fail to detect it. Never omit, then,
in all doubtful cases, to pass the hand over the abdomen, and
by the aid of both hands, to satisfy youi-self as to the shape
and size of the uterus. This method, termed by Di\ Marion
Sims the bi-manual method, often affords valuable informa-
tion. To cany it out, pressure is made with the left hand
over the pubes, while the index finger of the right is kept in
contact with the cei-vix uteri; the patient, lying on her back,
should be made to expire deeply, and, at this moment, the
fingers of the left hand should be pressed firmly down into
the pelvis, immediately over the pubes, while the index finger
presses the uterus upward from the vagina. It will thus, to
use Dr. Sims’ words, “be easy to measure the size and shape
of the body of the womb, for it will be held firmly between
the fingers of the two hands, and its outline and irregularities
will be ascertained with as much nicety as if it were outside
the body.” In thin subjects the results here enumerated
can be attained ; but in fat or very muscular women
we sometimes fail in our efforts to feel the uterus at
all through the abdominal parietes. Still, even with these
exceptions, the bi-manual method of examination is often of
great value.

I have already told you, that in order to arrive at an
accurate diagnosis, it is generally necessary to make a digital
examination of the condition of the uterus and vagina, and
to use both the speculum and the uterine sound. But in
many cases the two latter modes are not only unnecessary,
but positively forbidden. Thus, if on inti'oducing the finger
into the vagina, you detect cancer of the os uteri, the intro-
duction of the speculum becomes unnecessary, and may be

DISEASES OF WOMEN.

injurious, while the use of the sound is altogether prohibited;
or if, on using the speculum, we find the os and cervix uteri
in a state of ulceration, the symptoms the patient is
suffering from will probably be accounted for, and the intro-
duction of the sound into the uterine cavity is uncalled for,
and should be therefore avoided. So your examination in all
cases is to be progressive, the finger always being used in
the first instance. Any departure from this course I deprecate
strongly.

Further, in a certain number of cases it is necessary to
introduce the index finger into the rectum, in order to decide
certain points which your previous examination failed in
determining. Thus, with the finger in the rectum and the
sound in the uterus, you can ascertain whether a tumour
lying in the posterior cul tie sac is attached to the uterus or
not. In like manner, the sound being introduced into the
bladder and the finger in the rectum, the absence of the
uterus may be detected, or an inverted uterus distinguished
from a polypus.

I have now, Gentlemen, described very briefly the
mode in which you arc to investigate cases of supposed
uterine disease. But without a knowledge of what is thus
to be learned, the examination itself will be useless.

In my future lectures, I will call attention to the symp-
toms of, and the mode of treatment adapted to, the various
forms of uterine disease, as suitable cases for their illustra-
tion may from time to time present themselves.

LECTUEE II.

Lencorrlicea — Definition of— Characteristics of — Sources of —
Vaginal — Cervical — U terine — Vaginitis — Causes of —
Treatment — Clitoridectomy — Vaginismus.

It is a matter of much regret that the nomenclature of the
diseases peculiar to women is so vague and indefinite;
terms which in reality only express a symptom, the result of
very various pathological conditions, being commonly used as
indicative of a special disease. Thus we hear it said that a
patient is suffering from “leucorrhoea,” or it may be from
“ menorrhagia,” while in point of fact these terms should
only convey the idea of a prominent symptom. To-day I
propose to call your attention to the subject of leucorrhoea;
a word which literally means a white discharge, and for which
the popular synonym is “the whites.” It is a symptom
met in connexion with affections differing widely the one
from the other, while the discharge itself varies greatly in
colour, in consistence, and even in chemical properties. It
is essential that you should bear in mind that although, as I
have stated, leucorrhoea means a white discharge, the term is
to be understood in a relative sense as opposed to a red sangui-
neous one, and that it includes all non-hsemorrhagic vaginal
discharges. Thus very frequently it is of a light cream colour,
sometimes of a yellow, or again of a greenish tinge ; but
nevertheless, the patient will generally tell you that she
has “The Whites.”

In its natural healthy condition, the vagina, while moist,

DISEASES OF WOMEN.

should not secrete any appreciable discharge ; but hardly any
departure from a perfectly healthy state of either the vagina
or uterus ever takes place without leucorrhoea in some of its
forms being present. You cannot have failed to remark,
Gentlemen, the extreme frequency of this symptom among
the patients who have presented themselves here, and yet
you have seen that the affections from which they suffered
were very various. But before reminding you of the differ-
ent abnormal conditions on which, as I have from time to
time pointed out, these discharges depend, I must briefly
enumerate the main characteristics they present, and the
sources from which they proceed.

As already mentioned, the term leucorrhoea includes a
great variety of non-hsemorrhagic discharges. It very com-
monly presents itself as a profuse mucous discharge, inodor-
ous and light in colour, or again, as a thick creamy fluid,
coating the whole surface of the vagina, and flowing into the
speculum as you introduce it; then you have seen it so evi-
dently purulent that, as I have pointed out, it was impossible
to say whether it was the result of gonorrhoeal infection or
not; in other patients it presented a curdled appearance, or
lastly, was seen as a thick, tenacious, glairy secretion, issuing
from and filling up the os uteri. Now it is quite evident
that these various forms of leucorrhoea must not only depend
on different causes, but also must be secreted by different
parts of the genital canal. Accordingly, we find vaginal
leucorrhoea, cervical leucorrhoea, and uterine leucorrhoea, to
exist as three distinct affections.

The discharge, when proceeding from the vagina, is gener-
ally a light-coloured, creamy-looking fluid, unless acute
vaginitis be present, when it may become almost purulent :
it often is secreted from the whole surface of the vagina, but
in some cases, especially in children, it seems to proceed

LEUCORRIICEA.

mainly from the vulvo-vaginal glands. Again, in some forms
of ulceration of the cervix uteri, the discharge is profuse and
semi-purulent. That poured out by the cervical glands is
very different in character; the glands situated in this part
of the uterus are very numerous, and when inflamed secrete
a copious, tenacious, albuminous fluid, closely resembling in
appearance the white of egg; this discharge is so remarkable
and so pathognomonic of disease of the cervical canal, as to
be unmistakable. Lastly, you may have leucorrhcea pro-
ceeding from the interior of the cavity of the uterus itself.

The occurrence of this form of leucorrhcea is less easily
recognizable than any of the others, but of its existence as a
special affection I entertain no doubt; it is seldom that any
discharge, other than the glairy mucus secreted by the
cervical glands, is seen to issue from the os uteri, but there
is ample evidence to show that a copious discharge is, under
certain circumstances, poured out from the mucous mem-
brane lining the body of the uterus. This membrane at each
menstrual period undergoes a great change, fitting it for the
reception of the impregnated ovum, should such reach it — a
change aptly termed by Dr. Aveling* “Nidation”— or, con-
ception failing to occur, a process of degeneration takes
place, and it is expelled in minute portions, or sometimes,
though larely, as a perfect sac. This great and frequently
recurring change in its condition predisposes to the occur-
rence of disease; in addition to which there is also to be taken
into consideration, the vast alterations which occur in it
during pregnancy, and subsequent to delivery or abortion.
As a matter of fact, we find that the approach of menstrua-
tion is in most women ushered in by the appearance of a
white, mucous discharge, which there can be but little doubt
is mainly secreted by this membrane ; therefore that a similar

* Obstetrical Journal of Great Britain and Ireland, No. XVI., July, 1S74.

c 2

DISEASES OF WOMEN'.

discharge should present itself when it is the seat of disease,
is to he expected. In physical characters, the discharge
issuing from this source is often not to be distinguished from
that secreted in the vagina; but, while the latter has an acid,
the uterine discharge has an alkaline reaction, and it is the
mingling together of these twm fluids of opposite reactions,
that gives rise to the curdled appearance sometimes seen
in the vagina.

The causes of leucorrhoea may be either constitutional or
local. Anything which debilitates the constitution is liable
to be accompanied by the appearance of a white discharge;
thus it is seldom absent when lactation has been unduly
prolonged; or again, if a woman be debilitated by a profuse
menorrhagia she is nearly certain to be further weakened by
the occurrence of leucorrhoea in the intervals between the
menstrual periods. Again, it is met with in delicate girls,
especially those of a leucophlegmatic temperament, in whom
there exists a tendency to phthisis, and not infrequently in
them it is the precursor, if not the cause, of the lung disease.
Dr. Bennet, who for several years was engaged in practice
at Mentone, a favourite resort, as you are aware, for con-
sumptives, remarked that great improvement frequently took
place in the condition of many patients threatened with
phthisis in whom leucorrhoea existed, on that discharge
being checked by appropriate treatment ; an observation ca-
pable of easy explanation, if we bear in mind how exhausting
must be the effect of a profuse discharge so rich in albumen
as leucorrhoea is.

In cases which come under either of the heads I have
alluded to, namely, debility arising from over-lactation, or
from the effects of a weakly strumous constitution, our treat-
ment must be twofold ; in the first place, to endeavour to check
the debilitating discharge, and then to invigorate the consti-

VAGINAL LEUCORRIICCA.

tution and improve the general health. With the view of
effecting the former, you will order the use of astringent
vaginal injections, those of alum or sulphate of zinc are the
best, from two to four drachms of either salt being dissolved
in a quart of tepid water. This quantity should be injected
twice a day into the vagina by means of an ordinary syphon
syringe, and at the same time you should by change of air,
when possible, by the adoption of a generous diet, and by
the j udicious administration of tonics, of which the prepara-
tions of iron are especially appropriate, endeavour to improve
the patient’s general health. But other cases of leucorrhoea
are met with less amenable to treatment than these — namely
those which depend on the existence of visceral disease, such
as that of the liver or kidney, cases in which special treat-
ment can do no good, and therefore is to be avoided. It
would be tedious and unprofitable, however, for me to enu-
merate all the constitutional causes which predispose to the
occurrence of leucorrhoea. I may briefly sum up this part
of the subject by saying, that any disease which debilitates
and enfeebles the health, is likely to be sooner or later
accompanied by leucorrhoea.

But in addition to the numerous cases depending on
disease of other organs, or of the system at large, w-e meet
with leucorrhoea as a symptom of local disease, and of none
more frequently than that of inflammation of the vagina
itself, or vaginitis as it is termed. You have seen over and
over again examples of this.

The mucous membrane lining the vagina, in common with
that of all other parts of the body, is liable to inflammation
of both an acute and chronic character; the latter, however,
is much the more common. We have recently had under
treatment two well marked instances of acute vaginitis, one
in a young w^oman, J. McC . She stated that she had

DISEASES OF WOMEN.

been manned for four years but bad never been pregnant.
She complained of burning pain in the vagina, of pain in the
back, and of scalding in making water. On examining her,
the entire length of the vagina was seen to be of a bright
scarlet colour; it was tender to the touch, the introduction!
of a small speculum, and even of the finger, giving great pain.

As the speculum was being introduced, we saw a copious
purulent discharge of a greenish-yellow colour pour out
from its sides. The mucous membrane covering the os uteri
was bright pink, the cervix itself being evidently congested.

Now these cases of acute vaginitis are rare, and I always
look on them with suspicion; accordingly I questioned this
patient closely as to the possibility of her having contracted
gonorrhoea; she said it was impossible; but be the cause
what it may, we had here to deal with a case of acute in-
flammation of the mucous membrane of the vagina, and I
treated it as I would similar inflammation occurring in any
other part of the body. If an oculist meets with a case of
acute ophthalmia, he endeavours, in the first instance, to
arrest the progress of the inflammation by local blood let-
ting; I advocate the same practice in acute vaginitis. You
may remember that in this case I punctured the cervix freely
and encouraged the bleeding, and ordered her saline purga-
tives, but I did not, in the first instance, make any applica-
tion to the vagina. Caustics or astringents used at this
stage would only have done harm. In the case I am referring
to I purged the patient freely, and punctured the cervix
at intervals of a few days, on each occasion abstracting a
good deal of blood; and when the acuteness of the inflamma-
tion had subsided, ajiplied to the vagina a solution of nitrate
of silver, ten grains to the ounce, and subsequently a stronger
one. At the end of two months this young woman returned,
having in the interval become pregnant. Now had this woman

SUB-ACUTE VAGINITIS.

been in hospital instead of attending as an out-patient I
should, in addition to the local abstraction of blood by
puncturing or by leeches and the exhibition of purgatives,
have prescribed warm hip-baths, and directed hot water*
vaginal injections, at least twice daily, which would not only
have expedited the cure, but also have alleviated the woman’s
sufferings, and these are the means I recommend you to adopt
in your future practice. The foregoing case afforded a good
example of the difficulty of deciding between simple acute in-
flammation of the vagina and that depending on gonorrhoeal
infection. I must avow that I know of no means of distinguish-
ing with any cei’tainty between the two.

I have already said that cases of acute vaginitis are of infre-
quent occurrence; but, though acute vaginitis is not very
often seen, sub-acute inflammation of the vagina, accompa-
nied by leucorrhoea, is common enough, and is the cause of
much suffering. The pruritus, the burning pain in the vagina,
the frequent desire to micturate, and the scalding on doing
so, though not so severe, as in cases such as the one I have
just detailed, are constant and most distressing. The causes
of these attacks are various: you meet them sometimes in
young healthy women, who generally attribute them to cold,
but they are seen more frequently in married women in whom,
in addition to the causes named, I am inclined sometimes to
attribute their occurrence to the effect of too frequent sexual
intercourse, of intercourse occurring too soon after a men-
strual period, or before the vagina has regained its normal
condition after delivery.

There is one form of sub-acute vaginitis which gives rise
to very distressing symptoms ; in it we see aphthous looking
patches on various parts of the vagina. I have invariably re-

* For directions as to the mode of carrying out this treatment, see Lecture
XVII.

DISEASES OF WOMEN.

marked that this condition of the vagina is accompanied by
most distressing pruritus; not that pruritus does not occur
in cases of vaginitis in which these aphtha) do notexist,
for on the contrary, pruritus is a very common accompani-
ment of sub-acute vaginitis, but it is most marked, and nearly
if not always present in conjunction with them. And here let
me impress on you the uselessness of attempting to treat
itching about the vulva, without first ascertaining what the
condition of the vagina and uterus may be; for you will
seldom fail to discover, either that inflammation of the
mucous membrane exists, or that the uterus is congested or
ulcerated, and till these be cured, all your efforts to relieve
the pruritus permanently will fail. If vaginitis alone exist,
you will, with the view of attaining this object, and at the
same time of checking the pruritus which it causes, use in
the first instance soothing applications and then astringent
ones. Of the former none can compare with infusion of
tobacco. It should be made by infusing from half a drachm
to a drachm of the unmanufactured leaf in a pint of boiling
water. The infusion thus prepared shou'd be injected into
the vagina twice a day. It is necessary, however, to exercise
some caution in using it, for if the orifice of the vagina be
very narrow, some of the infusion may be retained in that
canal, and nausea and vomiting result from its absorption
into the system.

An infusion of hops, made by infusing an ounce of hops in
a quart of boiling water, is another very soothing remedy.
It may be employed without the risk of the occurrence of the
unpleasant symptoms which occasionally follow the use of the
infusion of tobacco; infusion of linseed also forms an excel-
lent and soothing lotion.

When the acute symptoms have abated, the addition of
borax, in the proportion of a drachm to the pint, adds greatly

TREATMENT OP VAGINITIS.

to the efficacy of either of these infusions, or a solution of
borax in tepid water, may, if preferred, be employed. Very
often, indeed, great good may be effected by injecting the
vagina with plain hot water, provided it be done efficiently;
but I must refer to this subject again.*

The itching in these cases is sometimes almost intolerable.
To relieve this most distressing symptom, I am in the habit
of recommending the patient after she has syringed or
sponged herself with warm water, to lay inside the labia a
piece of lint soaked in a lotion composed of carbolic acid, ten
grains; acetate of morphia, eight grains; dilute hydrocyanic
acid two drachms; glycerine, four drachms, and water to four
ounces. Sometimes when the vagina is excessively tender,
medicated pessaries containing acetate of lead or tannin do
good ; but I do not think that any kind of pessary can bo
x'elied on. Dr. Greenhalgh recommends their being made
with glycerine and gelatine, and containing whatever medi-
cinal substance maybe desired; such doubtless possess the
advantage of not producing the disagreeable greasy discharge,
which those made in the ordinary way do.

Another mode of treatment, of the greatest value, is by
the application of glycerine. A roll of cotton wool, or of
wadding, with a strong thread attached to facilitate removal,
is to be saturated with glycerine; this is then introduced into
the vagina through a speculum, and left in situ for twenty-
four hours. The glycerine, by its affinity for water, produces
a copious serous discharge which often, in a marked degree,
relieves the congestion that exists. In a future lecture,
however, I will refer at greater length to the local use of
glycerine in uterine affections.

You will often find that vaginitis is associated with a weakly
state of the constitution, and that you are called on to adminis-

* See Lecture XVII.

DISEASES OF WOMEN.

ter tonics; of these the mineral acids seem especially useful.
But it does not follow that because you cure the vaginitis
the leucorrhcea will disappear. Sometimes it continues when
all symptoms of inflammation have subsided, and then you
can use freely and with great advantage, as injections, solu-
tions of alum, two drachms, or of sulphate of zinc, one
drachm, to the pint; but often all our efforts fail to check
entirely the discharge, and it becomes chronic or disappears
only after a long interval. Before leaving the subject of
vaginitis, let me caution you against pronouncing every little
blush of redness that may be seen on the vagina to be in-
flammatory, or of attributing all the symptoms the patient
may complain of to that affection.

In nearly every case of leucorrhcea the discharge is much
more profuse immediately after the menstrual period has
terminated, and occasionally it seems to take the place of the
latter, which is then suppressed. In these latter cases the
leucorrhcea is profuse at the date when menstruation ought
to occur, and lessens considerably, or nearly disappears, for a
time corresponding to the interval between the ordinary
periods. This is likely to occur when the patient is debili-
tated by prolonged lactation, or by the existence of some
constitutional disease. A white discharge, accompanied occa-
sionally by a good deal of vascularity and irritation of the
orifice of the vagina, is also not unfrequently met with in un-
healthy strumous children ; and this has sometimes given rise
to a suspicion that the child had been injured by an attempt
at sexual intercourse. You must exercise great caution in
such cases in giving an opinion ; but, unless strong confirma-
tory evidence exists, showing that an attempt at penetration
has been made, I would have you slow in encouraging the
idea. You may have recently seen an example of such a case
in the children’s ward; the little patient was but six years old.

TREATMENT OF VAGINITIS.

Cleanliness and a nutritious diet, with the exhibition of iron,
speedily improved her condition. I also passed a camel’s
hair pencil saturated in a solution of nitrate of silver, up the
vagina every four days, and she was soon quite well. You
must also bear in mind, that irritation about the vulva may
be kept up in children by the presence of worms in the
rectum. Even in adults the possibility of leucorrhcea de-
pending on irritation existing in the rectum must not be
overlooked. Thus among our extern patients you recently
saw a young woman in whom vaginitis was kept up by the
presence of tape worm.

I may here allude to a trifling, though very troublesome
affection not unfrequently met with in females, and which is
often accompanied by a leucorrhceal discharge; namely, the
occurrence of little vascular mucous tumours, growing round
the orifice of the urethra. These frequently give rise to con-
siderable irritation, and even actual pain, the passage of the
urine over their surface sometimes causing much suffering.
Their removal is a matter of difficulty. Caustics generally
fail, while considerable bleeding has followed attempts
to extirpate them. The late Dr. Beatty was in the
habit of passing a ligature of fine iron or silver wire round
them, with Wilde’s snare for aural polypi; but the means
most likely to be followed by permanent cure, will be found to
consist in cauterizing them by means of the galvanic cautery.

Hitherto I have spoken only with reference to discharges
of purely vaginal origin; we have besides, however, not only
cervical but uterine leucorrhcea. It is also nearly certain
that in some forms of disease of the Fallopian tubes, a dis-
charge is secreted which finds its way into the uterus and
thence to the vagina, but it is very difficult, if not impossible,
to diagnose the existence of Fallopian disease during life.

You are all aware of the appearance which cervical leu-

DISEASES OF WOMEN.

corrhoea presents, I have called your attention to it so fre-
quently. In its healthy condition the cervix uteri secretes
a transparent viscid fluid in such small quantities as not in
general to attract any attention, or be observed, when the
speculum is introduced; but, when the cervical canal be-
comes the seat of inflammation, this secretion becomes not
only much more profuse, but also more thick and tenacious,
blocking up the os uteri, and hanging out of it as a thick
rope of viscid mucus which it is almost impossible to wipe
away. Cervical leucorrhoea, or as it is sometimes called,
“ cervical catarrh,” is an effectual bar to pregnancy, in this
contrasting with the other forms of leucorrhoea which do not
necessarily cause sterility.

The condition of the cervix giving origin to cervical leu-
corrhoea is one very difficult to cure; to do so, you must
treat the whole extent of the cervical canal, and this can
seldom be accomplished without applying to its whole length
a strong caustic, such as the fuming nitric acid, to the latter
of which I give the preference; the application of solution
of nitrate of silver, and even of the solid nitrate itself, will
seldom be sufficient. If the case be not of vei-y old standing,
the introduction of one of the solid zinc points, as suggested
by Dr. Braxton Hicks, often does good. You have seen me
apply them several times with success ; they cause a good
deal of local irritation, and give some pain, but this soon
passes off. The chances of this occurring may, however, be
much lessened, by placing in contact with the os uteri, after
the zinc point has beeh introduced, a roll of cotton saturated
with glycerine. At present, however, I can only glance at
the treatment of this most obstinate affection; I shall return
to it again when the subject of ulcerations of the cervix uteri
comes before us.

I have already stated that leucorrhoea may proceed from

CERVICAL LEUCORRIKEA.

the interior of the body of the uterus ; the diagnosis of this
form is less easily made than that of the others. It is
generally accompanied by a greater or less amount of pain,
which is not necessarily present in either of the other forms.
The reason of this is easily understood, for uterine leucorr-
hcea is, I believe, nearly always the result of disease of
the lining membrane of the womb. When leucorrhoea is
vicarious with, or, as already stated, takes the place of, the
regular menstrual discharge, it probably proceeds from the
interior of the uterus.

Perhaps the present is the most suitable time I shall find
for alluding to a practice, unfortunately of not very rare oc-
currence, which, while it destroys the health of the body, if
persisted in, impairs in no less a degree the powers of mind
and which is nearly always accompanied by leucorrhoea — I
allude to masturbation. I do not believe all I have heard as
to its great frequency, but that it is practised by many
females is too true. In some, I have no doubt, it has been
the result of uterine disease, the habit having been contracted
accidentally in the first instance, in the efforts to procure
alleviation from the irritation which so often exists about
the orifice of the vagina; but, be the cause what it may, it
is soon accompanied by vaginitis and endo-cervicitis, mani-
fested by the presence of the well-known, glairy, cervical dis-
charge. Beware, however, of charging a patient with being-
addicted to this degrading habit, because suspicious symp-
toms present themselves; the dilated pupil, the downcast
look, the uncontrollable excitement which a vaaiual
examination causes, generally tell the tale; added to this,
there is often a severe lancinating pain complained of im-
mediately over the pubes, and in several cases I have noticed
that vomiting at night has been a prominent symptom.
The habit if carried to any extent also often gives rise to
vaginitis and even eudo metritis of an obstinate form, as well

DISEASES OF WOMEN.

as to serious constitutional symptoms, of which menorrhagia
is probably the most common. These distressing cases can
be cured by moral means alone; local treatment is useless,
and generally injurious, for it attracts the patient’s attention
to the genital organs, the very thing we should be most
anxious to avoid. The administration of bromide of potas-
sium in thirty grain doses is however sometimes beneficial.
I cannot find words sufficiently strong to condemn, as I
would, the barbarous practice of mutilating the patient by
the removal of the clitoris. This operation is as useless as
it is disgusting; for there is no truth in the idea that in the
clitoris alone is seated the nervous expansion which subserves
the sexual orgasm.

There is a condition of the vagina, or, to speak more
correctly, of the orifice of the vagina, to which the term
vaginismus is applied, the result apparently of some irritation
of the nerves supplying the sphincter, or constrictor vaginae
muscle, and which sometimes causes much distress. Any
attempt at sexual intercourse, or even at introduction of the
finger, producing spasmodic closure of the canal. In some
cases this condition is evidently the result of inflammation,
and can only be relieved by the use of soothing applications,
such as those already recommended in cases of ordinary
vaginitis, and by leeching. In addition to these means, Dr.
Barnes recommends that the patient should wear a cylindrical
vaginal pessary made of India-rubber, which is to be inflated
with air after its introduction; this acts beneficially by
keeping apart the irritable and inflamed walls of the vagina,
and moreover, according to Dr. Barnes, by the “ mechanical
support it affords to the vaginal walls, subdues the morbid
contractility of the muscular tissue.”

In other cases, however, no inflammation exists, except it
may have been produced by attempts to forcibly overcome
the spasm.

DYSPAREUNIA.

Dr. Marion Sims is of opinion, that under such circum-
stances the hymen itself is the seat of the excessive irritabi-
lity, and he has succeeded in perfectly curing several patients
by dissecting out the hymeneal membrane, and afterwards
dilating the vagina by means of glass dilators ( Uterine
Surgery, page 335). Vaginismus, in an aggravated form, is
not of frequent occurrence, but cases exhibiting minor de-
grees of spasm are met with in px’actice from time to time.

Vaginismus is, however, a rare affection, and you must be
careful not to confound with it those not uncommon cases
in which sexual intercourse is simply painful, a condition
termed by Dr. Barnes “Dyspareunia.” This condition, in
the majority of cases, depends on inflammation of the vagina
or cervix uteri, but occasionally its causes are obscure, and
. baffle, or for a long time resist, our efforts to effect a cure.

LECTURE III.

Menstruation — Amenorrhoea — Causes of — Local and Constitu-
tional— Treatment of Various Forms — Use of Galvanic
S t em Pessary — Medical Agents.

By menstruation, as you are aware, is understood that
periodic sanguineous discharge which occurs in the human
female at regular intervals of .about four weeks, aud marks
the period of ovulation. Its first appearance in the majority
of girls takes place in their fourteenth or fifteenth year, but
it may be, and frequently is, deferred to a much later period
without the health being impaired. The discharge itself is
blood mixed with mucus, and with shreds of the mucous
membrane lining the body of the uterus. ri he blood pro-
ceeds from the uterus, as has been proved beyond all
possibility of doubt; for, in cases of inversion of the uterus,
the blood has in several instances been seen to flow from the
everted surface; but, although the discharge proceeds from
the uterus, the function depends on the ovaries, both for the
stimulus necessary for its first appearance, subsequent regular
recurrence, and due performance. These organs, as you
have learned elsewhere, become congested as the period
approaches, and finally extrude the mature ovum, while the
uterus, participating in the same condition, assumes a state
of activity; a membrane is developed which lines its cavity
and which affords a favourable nidus to the ovum should it
become fecundated ; or that failing to occur, it becomes disin-
tegrated and is cast off with an escape of blood in a sufficient

MENSTRUATION.

quantity to relieve the congestion which has temporarily
existed. The most careless observer must see how slight a
cause may disturb the equilibrium, which nature designs to
be maintained during the performance of this nicely-adjusted
function, and how a chill, or other suddenly acting cause, by
checking the menstrual discharge, may lay the seeds of
uterine disease.

As already stated, the majority of females commence to
menstruate during their fourteenth or fifteenth year; iu
many, however, the discharge does not show itself till a much
later age. The interval which elapses between each period
varies a good deal in different women; it should not, how-
ever, be less than twenty-one, or exceed twenty-eight, days ;
the duration of the period, too, varies much ; in some extend-
ing over but two or three, in others continuing for six or
seven days; if these limits be exceeded menstruation cannot
be looked upon as being strictly normal, though instances
are met with in which a considerable departure from the
foregoing standard occurs, and yet the health in no way
suffers. The reproductive powers of the female cease with
the cessation of menstruation, which occurs at a date even
more irregular than does the first appearance of the flow,
and this period, termed by some “the change of life,” by
others the “climacteric period,” is a time marked by a
special tendency to the development of disease.

The departures from normal healthy menstruation are
numerous. Menstruation may be scanty or profuse; it may
occur only after long intervals, or return after the lapse of
but a few days; it may be painful, or, finally, not appear at
all. The latter condition is probably the rarest. Amenorr-
lioea, taken in the limited sense of total absence or suppres-
sion of menstruation (the suppression of menstruation during
pregnancy being of course excluded), is not by any means so

DISEASES OF WOMEN.

frequently met with, as are the other forms of derangement
of the menstrual function ; but, if taken in the more extended
sense of greatly diminished menstruation, it comes commonly
enough under our notice, and it is in this latter sense that
we must consider the subject.

Cases of amenorrhcca naturally divide themselves into two
classes; namely, those in which menstruation has never
occurred, or, if at all, in a very imperfect manner; and those
in which the function once normally performed, now appears
irregularly and with a scanty flow, or has ceased entirely.
Each of these, again, must be subdivided into two other
classes, as the amenorrhcca depends on local or constitutional
causes.

It is self-evident that for the due appearance of the
discharge, no less than for its regular return, both the
ovaries and the uterus must be in a normal state; for, though
poured out from the inner surface of the lattei, the stimulus
essential to produce menstruation must proceed from the
ovaries. If, therefore, the ovaries be absent, diseased, or
imperfectly developed, or if the uterus be wanting or rudi-
mentary, the discharge will not appear at all, or at best, as
a mere sign. There is generally. much difficulty in deciding
whether the ovaries are at fault or not ; if the patient be
well formed, if the breasts have become full and round, and
if, in addition, the symptoms known as the “menstrual
molimina” show themselves, we may conclude that it is not
from any fault in the ovaries that the non-appearance of the
discharge depends. These symptoms, in addition to numer-
ous vague nervous sensations, consist of pain in and fulness
of the mamma), which sometimes becomes swollen and haid,
of pain in the ovarian region; weary aching across the loins
and down the thighs; of flushings and headaches, and some-
times of nausea. If all these symptoms be wanting, there is

AMENOBKHCEA.

strong reason to suspect that the absence of menstruation
depends on some abnormal condition of the ovaries; but
what that condition may be, can seldom be known during
life.

In the majority of cases in which the absence of the men-
strual molimina leads us to suspect that the ovai’ies are
absent or defective, the patient’s general contour is imperfect
and the stature stunted; but this is not by any means
necessarily so. There is a woman at present attending our
out-patient department, whose case I called your attention
to the other day. She is well formed, aged about thirty,
and has been married for about four years. Menstruation
occurs, she tells you, only at intervals of three months or
upwards, and she adds, that until after marriage she menstru-
ated altogether but some half-dozen times, at intervals of at
least twelve months. Sexual intercourse in her case has
evidently acted as an ovarian stimulus, inducing the flow to
appear after shorter intervals and in increased quantities;
she has never been pregnant. I am of opinion that in this
case the ovaries, although present, are in a state of imperfect
development. I should add that the vagina and uterus are
in all respects normal.

Again, the uterus may be entirely wanting or only in a
rudimentary condition. No case in which the uterus was
altogether wanting has presented itself at this hospital since
my connection with it, but I must nevertheless refer to the
subject. Cases occur in which all the symptoms constituting
the menstrual molimina are present, and in which conse-
quently we may fairly conclude that the ovaries are normal,
and yet menstruation does not follow. In some of these the
uterus has been proved to be entirely absent. The diagnosis
on this point is not difficult to make, for if a silver catheter
be introduced into the bladder and the finger into the rec-

DISEASES OF WOMEN.

turn, the presence or absence of the uterus can be determined
with certainty.

But though cases in which the uterus is altogether want-
ing are rare, instances of an imperfect or rudimentary
condition of the organ are from time to time met with. The
following one recently came under my observation : the patient,
a married lady, had never been pregnant; menstruation ap-
peared regularly, but was very scanty and lasted hardly a
day; the uterus measured but an inch in length, the vagina
too was very short, the entire length being only about two
inches; she consulted me on account of her sterility. In
such cases the protracted use of the galvanic stem pessary
has occasionally been productive of benefit, and in some in-
stances the uterus has elongated and increased in size under
the influence of the stimulus the instrument has afforded,
menstruation at the same time becoming more nearly or even
altogether normal. The shortening of the vagina is very
commonly met with in cases in which the uterus is imper-
fectly developed. In some instances that canal is entirely
absent, Dr. Sawyer exhibited a specimen of this condition
at a meeting of the Obstetrical Society, during the past
winter. The patient, from whose body it was taken, had
been for years under his observation. She suffered the most
intense paroxysms of pain for some days during each month,
caused, Dr. Sawyer believed, by the attempts the uterus
made to expel the menstrual fluid, and to force a passage by
which it might be discharged; after death a pouch was found
below the os uteri, distended with fluid. The evident total
absence of the vagina in this case deterred Dr. Sawyer from
attempting an operation. Lesser degrees of closure are,
however, more frequent, and afford fair promise of being
benefited by operation; and as serious consequences, and
even death, are likely to result if an exit for the menstrual

ATEESIA VAGINAS.

fluid be not obtained, the attempt to reach the upper portion
of the vagina by a careful dissection is certainly warranted.

But more important, because more common and more often
capable of being benefited by treatment, are those cases of
partial closure of the vagina which are occasionally met
with. This closui’e is sometimes of but limited extent, the
result of local inflammation, which may have been excited in
early childhood; but it occurs more commonly after tedious
labours in which the second stage having been unduly pro-
longed, sloughing has followed, and finally, the vaginal walls
have become united throughout a greater or less portion of
their extent. When the occlusion is the result of adhesions,
formed during infancy or early childhood, it is generally
situated low down in the vagina, at or near the vulva; but
if it be the result of sloughing following on protracted labour,
it is more likely to be met with in the middle or upper
third of the canal.

Both these forms are generally capable of being cured by
an operation, a small opening being first made which should
be gradually and carefully enlarged; but it would be impos-
sible to describe the steps of an operation, which must vary
in each case according to the part of the vagina at which the
occlusion is situated, its extent and the age of the patient.
In all cases, great care is necessary to prevent the adhe-
sions reforming. With this view the vaginal walls must be
kept apart by the intervention of a pledget of lint or of
cotton wool saturated with glycerine, and for a long time
after the surfaces have healed, the patient should wear a
glass dilator for two or three hours daily, for in these cases
there is always a great tendency in the vagina to contract.
The term atresia is applied to all cases of absence or closure
of the vagina.

Lastly, amenorrhcea may be occasioned by the presence of

DISEASES OF WOMEN.

an imperforate hymen, a condition, however, so rare that I
have met with hut one example of it. The hymen in that
case existed as a dense membrane, which bidged outwards
through the vulva, and was distended by the fluid which
filled the vagina. The patient was a girl aged about sixteen;
the fluid was first slowly and cautiously evacuated through a
small cannula, exit being thus given to a large quantity of
a dark inodorous fluid, and subsequently the membrane was
freely divided by a crucial incision.

Apart from these malformations which are compara-
tively seldom met with, certain local conditions occur which
interfere with the regular performance of menstruation and
cause amenorrheea. Of these none is more common than
congestion of the mucous membrane lining the body of the
uterus, the result of exposure to cold, or of some shock or
inflammatory attack. If a woman, during the menstrual
flow, be suddenly chilled, or remain sitting or standing for
a length of time in a damp, cold place, the flow is very likely
to be checked, congestion of the uterus, or at least of the
mucous membrane lining its cavity, being the result. This
condition may then become permanent, and till it be relieved
the discharge will not re-appear, or, if at all, in an imperfect
manner. Amenorrheea depending on this cause gives rise to
very distressing symptoms: the patient complains of pain in
the back, of a sense of weight in the pelvis, and, more es-
pecially, of headache. You have frequently seen instances of
this form of amenorrheea among the patients in the extern
department. These cases nearly always apply for relief dur-
ing the interval which elapses between two menstrual periods,
aud you must consequently at first limit your efforts to
relieve the prominent symptom, namely, the headache, and
not make any attempt to re-establish the flow till the time
comes round when it ought in the regular course to appear.

AMENORRIICEA.

With the view to the former, I almost invariably give mild
purgatives. In dispensary practice I usually prescribe a mix-
ture containing one ounce of sulphate of magnesia in eight
ounces of infusion of quassia), to which I generally add a drachm
and a-half of dilute sulphuric acid. Two tablespoonsful of
this mixture taken morning and evening, nearly always act
as a mild laxative; should it not, I direct a third dose to be
taken at mid-day. This simple treatment generally relieves
the head, and you must have repeatedly noticed that patients
have returned stating that the headache had entirely dis-
appeared, and sometimes that the discharge, which had been
suppressed, had again showed itself. Instead of the saline
purgative just alluded to, my colleague, Dr. James Little, is
in the habit of prescribing a pill containing one or two grains
of extract of aloes combined with one-sixth of a grain of
tartar emetic, to be taken each night at bedtime; a formula
which lie has found of great use in cases of recent standing,
occurring in girls of plethoric habit.

But often additional measures are necessary, and these you
are to have recourse to when the time at which the flow
should appear, approaches. You may direct the patient to
sit with her feet in hot water for fifteen minutes each night
for several days in succession ; by mixing two or three table-
spoonsful of mustard with the water you will greatly increase
the efficacy of this treatment; or what, in suitable cases, is
often more efficacious, employ the cold hip-bath, directions
for the use of which I will give hereafter.* If the patient be
plethoric the application of a couple of leeches to the verge
of the anus, or to the inner and upper part of the thigh, con-
stitutes a safe and often very efficacious mode of treatment.
Until you have succeeded in relieving the local congestion,
you should not have recourse to the exhibition of that class

* Soc Lecture XVI.

DISEASES OF WOMEN.

of remedies which stimulate the ovaries and uterus, and
which are known by the name of emmenagogues, for such
treatment would only aggravate the evil.

Cases, however, occur in which the uterus seems so sluggish
that though free from disease, it will not respond to the natural
stimulus which the ovaries should afford, and this though no
constitutional disease exists; these are the cases in which
means directed to stimulate the uterus do good, foremost
among which is electricity. A remarkable example of the
benefit of this agent came recently under my observation.
J. N., set. nineteen, a pale, strumous looking girl, had never
menstruated, but for some months past had periodically
vomited blood ; the vagina and uterus were normal ; strychnia
and other drugs were administered wi thout benefit. Medicines
were discontinued, and electricity was tried ; one pole of the
battery being applied to the sacrum and the other to the
vulva; this was repeated daily for a fortnight, when she com-
plained of intense headache, of pain in the back, and of sickness
of stomach; the next day the catamenia appeared freely, but
strange to say none of the symptoms subsided; the vomiting
was incessant and the febrile symptoms ran very high ; the
flow continued for six days, very freely, and then ceased, and
with it disappeared the febrile symptoms, the sickness of
stomach and headache. At the end of four weeks she again
began to suffer from headache ; electricity was again had re-
course to, and the catamenia re-appeared, this time unaccom-
panied by the severe symptoms which had previously marked
its advent.

There is another method of stimulating the uterus which
I have practised with much success in such cases. I allude
to the use of the so-called “Galvanic”* stem pessary. This

* While I retain the term “ Galvanic," as applied to this pessary, and say T have
found it of use, 1 do not wish it to be understood that 1 consider it to possess any

GALVANIC STEM PESSARY.

little instrument (Fig- 5) is made of copper and zinc, the
upper half of the stem being zinc, the lower copper, or, better
still, of two parallel pieces of copper and zinc united through-
out the entire length of the stem. Dr. Thomas, of New York,

recommends a further modification, and in some cases uses
a stem composed of alternate beads of copper and zinc, strung
together on a copper wire, thus making the stem flexible,
which is occasionally an advantage. The bulb to which
the stem is attached is hollow, and there is an orifice in its
under surface into which the point of a sound being inserted
the pessary can be carried up to the womb; the stem is
passed through the cervix till its point nearly reaches
the fundus, and the instrument is then left with the stem in
the cavity of the uterus. These pessaries are made of various
sizes and lengths, a matter of great importance, as not only
does the uterus vary in length in different individuals, but
the cervix also will in one case admit a stem much larger than
in another; you should therefore measure the depth of the
uterus before you attempt to introduce one of these pessaries,
and select one a little shorter than the depth of the womb;
taking care also that the diameter of the stem is suitable to

galvanic properties, which, as such, act on the uterus. There can he no doubt,
however, hut that when the two metals (copper aud zinc) of which the instrument
is composed, are in metallic contact, and surrounded by a fluid containing saline
matter in solution, a certain amount of electrical action goes on, and that when
the stem is introduced into the cervical canal, the salts contained in the uterine
secretions are decomposed, and corresponding salts and oxides of zinc and copper
are formed which act on the mucous membrane lining the uterus.

Fig. 5.

Galvanic Stem Pessary.

DISEASES OF WOMEN.

the capacity of the cervix; for if you introduce one with too
slender a stem it will immediately fall out, or if, on the other
hand, it be too thick the introduction will be a matter of great
difficulty, and even if introduced, the instrument will cause
so much pain as to render its removal a matter of necessity.

It requires some dexterity to introduce the stem, but a
little practice will soon enable you to overcome the difficulty;
if the cervix be very narrow it is better to dilate it a little by
introducing a single length of a No. 2 or 3 sea-tangle bougie,
but the necessity for this does not often occur. I leave this
instrument when introduced in situ, for three or four weeks,
unless it should cause irritation or pain, in which case it
should of course be removed ; but under any circumstances
the patient should be examined after a lapse of a month, lest
ulceration be produced, a result which never occurs if due care
be taken. If at the end of a mouth the desired improvement
in the state of the menstrual function has not taken place, it
is better to remove the instrument, and re-introduce it after
the lapse of a few days. I have several times seen the hap-
piest results follow the use of this instrument, both in the
case of young women who have never menstruated, or in
whom the function has been imperfectly performed, and also
in married women in whom it has been suspended for a time.
It is not so well adapted to the treatment of hospital patients
as to those we treat in private ; for it is very difficult to keep
the former in view for any length of time, or to get them to
return after the proper intervals to have the pessary removed.
You saw me introduce one, however, a few days ago, and the
case will be an interesting one to watch. The patient is a
married woman, fct. thirty-five; menstruation has not ap-
peared at all for the last three years; I cannot detect any
symptoms of either constitutional or local disease which can
account for this. Medicines having failed to do her good, I

AMENORRHCEA.

have suspended their use; we shall see what the pessary may
effect.

There is one form of irregular menstruation which must be
classed under the heading of amenorrhcea, for the function is
defectively performed. In this form the discharge appears
at the regular time, but stops after a day or so, to re-appeai
in, perhaps, twenty-four or forty-eight hours thus coming
and going at short intervals. This kind of “interrupted
menstruation, I have noticed several times, in connection
with chronic endo-metritis and thickening of the cervix. A
very good example of this is afforded in the case of a patient
at present under treatment in the pay ward. >She is a nurse-
tender, and was admitted complaining of severe pain in the
back and thigh, which incapacitated her from following her
occupation; there is some erosion of the lips of the os; the
uterus is heavy and anteverted, and the cervix greatly thick-
ened. Unless in her case we can cure this condition of the
uterus, menstruation will not again follow its normal course.

Cases of amenorrhoea depending upon constitutional
causes are of more frequent occurrence than those of local
origin. You must all be aware that suppression of menstrua-
tion, or its appearance as a mere sign, is often an early and
ominous symptom in cases of incipient phthisis, and fre-
quently it is the symptom for which we are consulted. Let
me here repeat the warning I have so often given you, when
such cases have presented themselves, not to yield to the
solicitations of the patient, or of her friends, to attempt to
restore the function by the exhibition of stimulating emmen-
agogues ; the attempt would be vain and the result disastrous
both to your character and to the patient’s health. Females
almost invariably look on suppression of menstruation as the
cause of their ill health, and will express day after day the
certainty they feel that health would be restored if the dis-
chai'ge could be made to re-appear, an assertion often true if

DISEASES OF WOMEN.

only read conversely; the re-appearance of the discharge in-
dicating that health had improved, but not being the cause of
that improvement. Thus some women menstruate regularly
when resident in certain localities, but never when compelled
to leave them. I saw some time since a lady who was quite
regular during a two yeai-s’ residence at Falmouth, though
for a long time previous to her going there menstruation had
been entirely suppressed. Business matters compelling her
to revisit Ireland, the amenorrhoea soon became habitual;
symptoms of phthisis rapidly developed themselves, and she
died in a few months of consumption. Need I add that in
such cases the lung disease, not the amenorrhoea, is the con-
dition calling for treatment.

All other forms of organic diseases come un der the same
category, as being frequently the causes of amenorrhoea ; but
it is not my province to enter on the treatment of these, and
the enumeration of them would be tedious. One constitut ional
disease, however, of which amenorrhoea is a prominent
symptom, calls for special notice; I mean anaemia, including
under that term chlorosis. In it, as you arc aware, the patient
presents a sickly yellowish-green colour. She complains of
pain in the back, of lassitude, and often of headache ; nearly
always the appetite is bad and the taste depraved ; the bowels
are constipated, and the tongue generally furred. These
cases are unfortunately too common among our town popula-
tion, especially among those poor women who work hour after
hour from early morning till late at night, earning a miser-
able pittance with the needle. With them we can do but
little; country air and a generous diet would soon work won-
ders for them, but the remedy is beyond their reach. In
many, however, some good can be effected by the exhibition of
tonics, and especially of iron, a remedy which above all others
is here indicated. As constipation is nearly always present
you should combine aloes with it; this greatly enhances its

AMENORRHfEA.

activity; two grains of the sulphate of iron, with a quarter
or half a grain of extract of aloes, taken three times a day
sometimes acts like a charm.

Another medicine of the highest value is strychnia; five
drops of the liquor strychnise, which is equivalent to the one
twenty-fourth of a grain of the alkaloid, gradually inci eased
to ten drops, three times a day, alone or in combination with
the tincture of the perchloride of iron, sometimes pioduces
the most beneficial results ; but I think it is more suitable to
those cases in which simple debility rather than a chloiotic
condition is present. Strychnia, I believe, acts as a powerful
stimulus to the ovaries, as well as a general tonic.

When no antenna is present, and where the indication seems
to.be rather to stimulate the ovaries and uterus, I have found
the combination of five drops of the tincture of iodine and
five of the solution of strychnia, productive of much benefit.

I shall allude to but one other constitutional cause of
amenorrheea. It is one of not very infrequent occurrence. I
mean a plethoric condition of the system. In such women
the complexion is high, the pulse strong; they suffer much
from flushing and headache, especially at the time men-
struation ought to occur. In such cases active outdooi
exercise, a moderately abstemious diet, and the exhibition
of the acid saline purgative already recommended in cases of
local congestion, will generally produce good results. We
should aim at establishing periodicity, and, selecting the time
in each month when the occurrence of the molimina indicate
that menstruation ought to occur, apply two or three leeches
to the inside of the thighs or to the verge of the anus; thus
relieving the local congestion, and thereby favouring the
chance of the natural flow appearing; or, if the patient be
married, puncture the cervix and abstract blood directly
from the uterus itself.

LECTUEE IV.

Dysmenorrhcea — Definition — Membrane thrown off during —
Spasmodic — Inflammatory — Cause of pain in — Typical
case of — Treatment of — Mechanical — Surgical.

Intimately connected with the subject of amenorrhcea, is
that of painful menstruation, or dysmenorrhcea, as it is
termed; a subject the pathology of which is still far from
being clearly understood.

Menstruation, like all the other functions of the body, to be
perfectly normal should be painless; but, in point of fact, the
majority of women suffer more or less pain and discomfort
before the appearance of, or during, the flow, while in many
the sufferings are very severe. In dysmenorrhoea, as a general
rule, the pain commences about twenty-four hours before the
discharge appears, increasing in severity as the period ap-
proaches, sometimes becoming so intense that the patient
cannot move about, but is compelled to lie down, and even to
roll in agony on the bed; occasionally, too, nausea and even
vomiting occur. In due time the discharge appears, and
then in many instances relief is obtained ; sometimes, however,
the pain lasts during the whole period, or becomes paroxysmal ;
again, not vei’y unfrequcntly clots, and sometimes shreds
are expelled per vaginam, and instances arc recorded in which
large pieces of membrane, and even a perfect cast of the en-
tire cavity of the uterus, have thus come away during attacks
of painful menstruation. This dysmenorrhooal membrane is

DYSMENORRHOEA.

an exfoliation of the mucous membrane lining the cavity of
the uterus, which is cast off as a perfect sac, instead of being
detached in shreds. Its expulsion has on some occasions
given rise to the suspicion of pregnancy; a suspicion, which
a careful examination of the bag will speedily dissipate, as of
course all trace of an ovum will be wanting.

Authors differ greatly as to the nature of the causes pro-
ducing painful menstruation; no theory has of late years been
so prominently brought forward, or so warmly advocated, as
the mechanical one. Mechanical dysmenorrhoca, and obstruc-
tive dysmenorrhoea, are terms you will hear constantly made
use of. Now, while admitting that mechanical obstruction
to the exit of the menstrual discharge occurs, I doubt that
it is as frequently a cause of painful menstruation as is gene-
rally stated; nor can I admit the correctness of the axiom
laid down by Dr. Marion Sims, “that there can be no dysmen-
orrhoea properly speaking, unless there be some mechanical
obstacle to the egress of the flow, at some point between the
os internum and the os externum, or throughout the whole
cervical canal.”* Such an unqualified assertion, made by a
■writer of such acknowledged weight, is calculated to produce
much mischief, by inducing surgeons to have recourse to
operative interference for the relief of dysmenorrhoea, which
in many cases may be wholly unnecessary.

For practical purposes I think it sufficient to class cases
of dysmenorrhoea under four heads; namely, 1st. Spasmodic,
or Neuralgic; 2nd. Congestive; 3rd. Inflammatory; and,
4th. Mechanical dysmenorrhoea.

In spasmodic dysmenorrhoea the pain, as in the other forms,
precedes the appearance of the discharge. In the majority
of cases it is met with, either in delicate girls of feeble con-
stitution, and leucophlegmatic temperament; or again, in
* Uterine Surgery, p. 143.

DISEASES OF WOMEN.

women of full habit, especially if they lead an inactive life.
I have pointed out to you from time to time, numerous ex-
amples of this form of painful menstruation in sempstresses,
and in poorly-fed over-worked servants. In these cases the
flow is in general scanty, and its appearance does not bring
any marked relief, the pain continuing more or less during
the whole of the period; it is not, however, always equally
severe, but is paroxysmal, being less so while the patient is
warm, but becoming aggravated by the least exposure to
cold. This form of dysmenorrhoea is by some writers de-
scribed as neuralgic ; its true nature, however, is very obscure,
but its attacks can almost with certainty be cut short by the
administration of sedatives and anti-spasmodics; and these
are the remedies you should prescribe. I generally give a
pill containing half a grain of opium, one of Indian hemp,
and two of camphor, at bedtime ; a combination which seldom
fails to give at least temporary relief; or if for any reason
opium is objectionable, I substitute for it two grains of the
extract of conium. In some cases the hypodermic injection
of a solution of morphia and atropia* affords relief, when
opium administered by the mouth or by the rectum has
failed.

When the attacks have become habitual, and the patient
is consequently obliged to have recourse regularly to the use
of medicines to obtain relief, I usually direct her to have by
her, ready for use, a mixture containing two drachms of sul-
phuric ether, half a drachm of the liquor opii sedath us, tluec
drachms of the tincture of hyoscyamus, one drachm of the
hydrate of chloral, two drachms of the spirits of chloroform,

* The following is the formula I use in such cases : Acetate of morphia, four
grains ; solution of atropia, four drops ; water, two drachms ten drops of this
contain one-third of a grain of morphia, the largest dose which should be admi-
nistered on the first occasion. It is safer to inject a small quantity at first, and
repeat the dose if necessary.

OVARIAN DTSMENORRHCEA.

and water sufficient to make a six-ounce mixture; of this she
should take a tablespoonful every two hours. Sometimes
five grains of lupuline, to be taken in the form of a pill,
thrice a day, from the time the first symptom of the ap-
proaching paroxysm is perceived, will stave off the attack
altogether. The patient should also take a warm hip-bath,
every night at bedtime for a week, before the expected recur-
rence of the menstrual period, and if prevented by the pain
from sleeping, have a full dose of the hydrate of chloral.
This treatment is, however, only palliative, and as the cause
generally lies in some fault of the constitution, or system at
large, our object should be to correct that condition by treat-
ment carried out during the interval between the menstrual
periods. If you can detect symptoms of imperfect digestion,
their removal is sometimes followed by relief of the dysmenorr-
hoea ; while if the patient be anamiic, the exhibition of iron,
or sometimes of arsenic, is of the greatest use. I am con-
vinced, however, that many cases of spasmodic dysmenorrlioea
are due to congestion of the lining membrane of the uterus,
and that this is specially the case in women of full habit,
who lead indolent lives, and in whom great benefit follows
from the adoption of more abstemious diet, and more active
habits, together with occasional use of saline purgatives.

In congestive dysmenorrlioea, the ovaries even more than
the uterus >are commonly engaged, though the latter organ
frequently participates in the abnormal congestion. In it,
the paroxysm is preceded by paiu in the ovarian regions, and
by a feeling of tension, often amounting to acute pain, in the
mammae, and sometimes by headache. The attacks may not
unfrequently be averted by the use of saline purgatives taken
immediately before their anticipated return; and if the case
be of any standing, by the administration of the bromide of
potassium, in from twenty to thirty grain doses, three times

DISEASES OF WOMEN.

a day. This treatment, or that of a similar character, direc-
ted to relieve or prevent the ovarian congestion, will gene-
rally prove successful.

Inflammatory dysmenorrhoea is a common affection, and
the sufferings due to it are often very acute; the pain how-
ever, is generally, although not always, relieved by the
appearance of the menstrual flow ; a fact capable of easy ex-
planation, for the loss of blood relieves the congestion which
exists, just as it would a similar condition in any other part
of the body. In this form, the uterus, or at least its lining
membrane, is in a state of chronic inflammation; sometimes
also there is associated with it an unhealthy condition of
the cervical canal; sexual intercourse is often painful in
consequence of extreme sensibility of the cervix, a not un-
common result of chronic inflammation of that part of the
womb. In the spasmodic form of dysmenorrhoea the pain is
nearly always referred to the back, or to the lower portion of
the abdomen. In inflammatory dysmenorrhoea, on the other
hand, it is often more intense along the edge of the false
ribs, generally on the left side, shooting up to the shoulder,
and down to the ovary of that side.

Now to what is all this suffering due 1 Are we to believe,
as is held by many, that it is caused by retention of the
menstrual discharge and consequent distension of the uterus
by fluid % A result supposed to be due to the closure of the
os internum by the swelling of the mucous membrane, which
occurs in consequence of the venous congestion always pre-
sent at the commencement of each menstrual period. That
this may be a cause of painful menstruation I admit, but
that it is a very frequent one, I much doubt. The history
of the following case is very instructive, and bears on the
point under consideration. The patient, a lady, ait. twenty-
eight, who had borne five children, the youngest but fifteen

INFLAMMATORY DYSMENORRHCEA.

months old, recently came under my care; her sufferings
dated back several years, during which time she had been
twice confined. For two or three days before the menstrual
period, which always recurred regularly, she suffered from
pain over the uterus, shooting up under the left breast and
round to the back. This was very severe during the first
day of the flow, then it gradually subsided, and she en-
joyed comparative ease for a time. Sexual intercourse has
been for a long time attended with pain. She did not com-
plain of the introduction of the finger into the vagina, but
the moment it touched the cervix, she cried out, stating
however, that the pain this caused was quite different from
that experienced at the menstrual period. The sound passed
with the greatest facility through the os internum, but
though there was no obstruction to its passage, the moment
it reached that point, she suffered the greatest agony ; and
though previous to the examination she had no pain, at this
instant she experienced a peculiar shooting pain, similar to
that from which she suffered so much during the menstrual
period.

Now this case throws some light on at least one variety of
inflammatory dysmenorrhoea. No obstruction existed here,
yet menstruation was excessively painful, and paroxysms
of pain, exactly similar to that suffered during menstrua-
tion, were caused by the passage of the sound through
the os internum. I believe that this patient was the
subject of chronic endometritis; that the lower portion
of the cavity and the os internum was specially engaged ;
that when the uterus became congested, as it does at each
monthly period, this inflammatory condition being necessarily
aggravated, caused the acute pain from which she suffered,
and that this was relieved, when the flow set in, as other
congestions arc relieved, by local depletion. I think further,

e 2

DISEASES OF WOMEN.

that the sufferings experienced by many women at each
catamenial period, are not mechanical, but are due to con-
gestion of the portion of the lining membrane of the uterus
indicated, the catamenial congestion rendering acutely sensi-
tive a part which, though in an unhealthy state, was not be-
fore the seat of pain. It is quite possible, and indeed very
probable, that the swelling and thickening of the mucous
membrane, which takes place when this congestion occurs,
may in numerous cases be sufficient to close the os inter-
num, and thus actually oppose a mechanical obstruction
to the exit of the menstrual discharge ; but I cannot concur
in the commonly held idea, that it is the general cause of
painful menstruation, or agree with Dr. Marion Sims, who
says “ that if there be much pain either preceding its erup-
tion, or during the flow, there will generally be a physical
condition to account for it, and this will be of a nature to
obstruct mechanically the egress of the fluid from the cavity
of the womb. The obstruction may be the result of inflam-
mation and attendant turgescence of the cervical mucous
membrane, whereby this canal becomes narrowed merely by
the tumefaction of its lining coat; but by far the most fre-
quent cause of obstruction is purely anatomical and me-
chanical.”

Now in the case I have just alluded to, the canal of the
cervix was so patulous that I do not think it possible the
lining membrane could swell to such an extent as to close
the passage ; and if the patient’s sufferings were in this case
due to mechanical causes, why should the passage of the
sound reproduce so exactly the pain of the menstrual period?
In my opinion it was caused by the os internum being in an
unhealthy condition, and that therefore anything which in-
creased the existing irritation, whether that were the passage
of the sound, or the congestion consequent on the approach

INFLAMMATORY DYSMENORRHCEA.

of the menstrual period, equally caused pain ; in fine, while
admitting the mechanical theory as serving to explain the
symptoms presented in a certain proportion of cases of dys-
menorrhoea, I deny that it does so in the majoiity.

The occurrence of congestion and inflammation causing
dysmenorrhoea is of course well known ; and in the foiegoing
remarks I merely desire to point out that in my opinion tho
seat of pain is in such cases at, or immediately beyond, the
junction of the body with the cervix uteri; that the cause of
the pain in many instances is endometritis, and that it is not
necessarily due to any actual obstruction to the exit of the
menstrual discharge. I may add that in the case just al-
luded to, local depletion and the subsequent application of
the fuming nitric acid, perfectly cured the dysmenorrhoea.

The treatment of inflammatory dysmenorrhoea includes
three indications.

1st. Removal of all causes keeping up the existing irri-
tation. Foremost among these is the abstinence from
sexual intercourse ; for not only does the act itself generally
cause pain, and therefore must be injurious, but the occur-
rence of conception is to be specially avoided. Riding on
horseback, fatiguing walks, or even household occupations
which necessitate much standing, should be given up,
while the occurrence of constipation is to be carefully
guarded against.

2nd. Relief of the uterine congestion. By local depletion,
either by means of leeches applied before the menstrual
period, or, by puncturing the cervix uteri and encou-
raging the bleeding: this latter treatment you have
seen me carry out repeatedly with considei’able benefit.
It is not suitable in the cases of young unmarried girls,
as it necessitates the use of the speculum. In them leeches
should be applied to the inside of the thighs, or to the

DISEASES OF WOMEN.

verge of the anus, but in married women to the cervix uteri
itself; mild purgatives should also be administered from time
to time. When by these means you have succeeded in re-
lieving the congestion of the uterus, considerable benefit
will be derived from blisters applied over the sacrum, or to
the abdomen a little above the pubes.

3rd. Excitement of healthy action in the uterine mucous
membrane. If the case be of long standing, and that the
symptoms though relieved, do not entirely disappear, show-
ing that a certain amount of endometritis still exists, I recom-
mend you to cauterize the cervical canal, and sometimes even
the whole interior of the uterus, with carbolic acid, or, in
many cases, better still, with strong nitric acid. I shall on
a future occasion explain to you the mode of carrying out
this safe, and indeed painless treatment.*

I have met with but little benefit from the exhibition
of medicines in inflammatory dysmenorrhoea. Where ovarian
excitement exists, bromide of potassium in twenty or thirty
grain doses, three times a day, does good; the bichloride
of mercury in small doses, and continued for a considerable
time, has bceu recommended by several writers; for myself I
must say it has disappointed my expectations. Purgatives*
especially the saline, seem to me the only medicines capable
of producing real benefit; these, to do good, should be ex-
hibited just before the menstrual period.

It remains for us to consider those forms of dysmenorr-
hoea which depend on mechanical causes. Of these, there
are three varieties; namely, those in which the cervical canal
is so flexed as to obstruct the escape of the menstrual dis-
charge : secondly, those in which inflammation or congestion
of the lining membrane exists to such an extent, as to cause
temporary closure of the canal, or of the os internum; and

* Sec Lecture XVII.

MECHANICAL DYSMENORRHCEA.

thirdly, those in Avhich from some congenital malformation,
or acquired cause, the os internum, or the cervical canal
throughout its entire length, is permanently narrow and con-
stricted. To this last may be added those cases in which
fibrous tumours are met in connexion with, and often caus-
ing, dysmenorrhcea.

Painful, or difficult menstruation, is frequently observed
in women in whom the uterus is flexed; but though flexions
of the uterus may, and certainly do, interfere with the exit
of the menstrual flow, they seldom do so unless the flexion
be complicated by the existence of chronic inflammation, or
the presence of a fibroid. In such cases we should certainly
endeavour to relieve the flexion, and see if by replacing the
fundus in its normal position, and supporting it there by a
pessary, we can relieve the patient before having recourse to
surgical means, which are less suitable in this than in any of
the other forms of mechanical dysmenorrhcea. Cases of dys-
menorrhcea are not unfrequently met with in women who,
although married, are sterile, in whom flexions of the uterus
exist, and in whom menstruation was prior to marriage, a
painless function. In the majority of these cases I believe
the flexion to have been congenital, and that marriage was
to them a positive evil ; producing congestion in a malformed
organ, and giving rise in turn to a long train of distressing-
symptoms. In these cases the uterus is generally ante-
flected; a condition of the organ which it is most difficult to
treat successfully.

I have already so fully explained my views as to the chief
cause of the dysmenorrhcea in cases of inflammatory swelling
of the lining membrane of the uterus, that I have but to re-
peat that, though not in my opinion of frequent occurrence,
cases are met with in which the os internum, or some portion
of the cervical canal, becomes so narrowed in consequence of
the tumefaction of the parts, as to present a mechanical im-

DISEASES OF WOMEN.

pediment to the discharge of the menses. In such cases,
the treatment I have already recommended fail, I have no
hesitation in having recourse to surgical measures with the
view of procuring relief; indeed it is obvious that an opera-
tion which divides the cervix, so freely as does that intro-
duced by Sir James Simpson, must be calculated to give
permanent relief to the congested organ. I only say again
that the operation should not be had recourse to till other
means have failed. I may here take the opportunity of
saying once for all, that I object to the use of
any of the means which have been suggested
for the purpose of dilating the cervix in the
treatment of dysmcnorrhoea. Several cases
of severe inflammation, and even of death, are
recorded as having followed such an attempt.

Moreover, this mode of treatment, whether
carried out by means of metallic dilators or
by sea-tangle bougies, is in other respects also
objectionable. It is slow, painful, and most un-
certain in its results ; for the cervix after a time
nearly invariably contracts, and the patient
relapses into her former unsatisfactory state.

Of all the instruments devised for the purpose,

Priestly’s Dilator (Fig. 6) is probably the
best. I have used it in cases in which
difficulty occurred in getting a sea-tangle tent
through a very narrow os internum ; but even
then, I only expanded the dilator to a very
trifling extent. Now I never employ it.

A contracted os, looking almost like a pin
hole, and leading up to a narrow cervix uteri,
is not unfrequently seen; this condition is
almost invariably associated with sterility,
and very often with dysmenorrhoea also. You saw last week

Fig. 6.

Dr. Priestly's
Dilator.

USE OF STEW PESSARY.

a very good example of this in the case of the young woman
who sought relief for the latter affection. Menstruation is
with her both painful and scanty ; the os uteri is so small
as hardly to admit the point of a probe; and there can be
no doubt but that the cervical canal is unduly contracted. I
think such cases as hers are fair subjects for operation, for
no other treatment will be productive of permanent benefit,
but beware of holding out hopes to your patient, that by
submitting to the operation she will gain more than lelief
from the suffering caused by the dysmenorrhcea. "W hen
the operation has been performed for the cure of sterility,
it has in general, as far as my experience goes, resulted in
failure; in other words, it is in my opinion a legitimate
proceeding, if performed wfith the view of curing cases of
dysmenorrhcea in which other treatment has failed, 01 is in-
applicable; but that it is seldom justified in cases of ste-
rility; because the narrow os and contracted cervical canal
are not the cause of the sterility, but merely an index of
some congenital condition or defect in the uterus itself which
hinders conception. What that defective condition may be
we may not be able to decide.

But the patient I have just alluded to is averse to under-
going any operation, and I have therefore introduced a slen-
der and short stemmed galvanic pessary. She has worn it
for three weeks, and it has already been productive of marked
benefit; for she tells you, that during the menstrual period
which has just passed, she was free from pain, and that the
flow continued for five instead of two days/' You saw that I
had some difficulty in introducing it, mainly because the
uterus is slightly anteflected. I had accordingly to expose

4 This patient continued for some time to derive relief from wearing the pessary,
but on removing it all her bad symptoms returned ; therefore, after the lapse of
many months, I decided on dividing the cervix. The operation proved suc-
cessful.

DISEASES OF WOMEN'.

the os with the duck-bill speculum, then to seize and draw
down the cervix with a fine hook, and while the womb was
thus fixed, slip in the stem of the pessary. You must always
adopt this method when difficulty occurs in the introduction
of these instruments. I have known much good to result in
such cases as the foregoing from this simple treatment; it is
at least worth trying before advising that an operation should
be performed.

The use of the stem pessary is also specially indicated,
where painful menstruation exists, with either i-etroflexion,
or anteflexion of the uterus ; for the stem not only renders
the canal patulous, but, by straightening the cervix, favours
the escape of the discharge. Unfortunately a certain amount
of endometritis commonly exists in such cases, and this fre-
quently prevents the stem being tolerated. To meet this
difficulty, Dr. Greenhalgh has invented a soft, flexible stem
pessary,* made of India-rubber, that can sometimes be worn
with comfort when a rigid one could not be borne.

But a large percentage of the cases we meet with in
practice derive no permanent benefit whatever from any form
of palliative treatment, nor can any favourable result be an-
ticipated, because some portion of the cervical canal, either
at the os internum, or throughout its entire length, is con-
tracted. In some patients the cervix is conical, and terminates
in a very small circular os uteri, “the pin-hole” os uteri, as it
is termed, the cervical canal being generally much contracted.
Dr. Barnes is of opinion, that in such cases the obstruction is
mainly due to the small size of the os itself; he consequently
rests satisfied with an operation which divides the cervix,
but does not divide the os internum. I much doubt, how-
ever, if the os internum is ever of its normal size where the
os externum and cervical canal are contracted. Certainly

Manufactured by Arnold & Sons, 34 West Smithficld, London.

DIVISION OP CERVIX.

the exceptions to this being the rule must be rare. I, there-
fore, in all cases divide the os internum as well as the os

externum and vaginal portion of cervix.

Now, with respect to the operation itself, we are indebted
for its introduction to Sir J. Simpson, who for a time practised
it very extensively, though I believe that before his death
his views on this point were considerably Fig. i .

modified, and that he did not perform it
nearly so frequently as he had done at an
earlier period of his career. His method
of performing the operation was by passing
an instrument termed a bistourie cache
through the canal of the cervix, and
within the os internum. It contained but
one blade, which, when the instrument
had penetrated to the requisite depth, was
made to protrude, the extent of the pro-
trusion being regulated by a screw. The
incision commenced at the os internum,
and as the instrument was withdrawn it
incised gradually and more deeply the sub-
stance of the cervix, until it divided the
vaginal portion quite through ; the instru-
ment had then to be turned, re-introduced,
and the other side divided in like manner.

This re-introduction is very objectionable,
and consequently various knives (metro-
tomes) have been invented with the view of
obviating it. Those proposed by Dr. Savage
and Dr. Greenhalgh are both good instru-
ments. I generally use the former (Fig. 7).

It is furnished with two blades, the cutting Metrotome.
edge of each being directed outwards; and as the back of
•each blade, when the instrument is closed, projects beyond

DISEASES OF WOMEN.

the cutting edge of its fellow which it thus overlaps, its
introduction into the cervix can be safely effected. It is
frequently necessary to dilate the cervical canal before this
step can be effected, and indeed it is generally requisite to
do so, no matter what instrument is used: one piece of sea-
tangle will however open the canal sufficiently for the pur-
pose. You should then, having exposed the os by means of
the duck-bill speculum and seized one lip with a hook, so as
to steady the uterus, proceed to introduce the knife, taking
care that it does not pass unne-
cessarily far into the uterus; the
blades are then expanded, later-
ally, slowly, and only to a limited
extent previously decided on ; for
if this precaution be neglected you
will divide the os internum too
deeply; a proceeding which may
cause alarming haemorrhage, and
is nearly certain to be followed
subsequently by such great ever-
sion of the lips of the womb, as
to leave the neck patulous and
gaping to an excessive degree.

This condition exists in a patient
at present under my care, who was
operated on by Sir J. Simpson ten
years ago. The metrotome, the
blades being kept expanded, is now
withdrawn; I think it better not
to divide the vaginal portion of
the cervix with them, but to com-
plete this part of the operation subsequently by means of
the scissors (Fig. 8).

With this object, the longer blade, which terminates in a

Fig. 8.

DIVISION OF CERVIX.

probe-pointed extremity, is introduced into the cervical canal
nnd through the os internum, the other blade is applied
Fig. 9. laterally to the vaginal portion of the cervix; the
part included between them is then to be divided
by the closure of the blades. When one side of
the cervix has been divided, the blades have to be
turned and the other side divided in a similar
manner. My reasons for completing the opera-
' tion in the manner described are, that to enable
' " the blades of the metrotome to cut through the

vaginal portion of the cervix, they must be ex-
panded to a degree which, without great care,
may permit of their incising the os internum to a
dangerous extent; while even when so expanded,
a sufficient division of the lower segment of the
cervix is not always made, and, moreovei, the
risk of hsemorrhage occurring is much lessened,
if not indeed altogether avoided, by following
the method I adopt.

Dr. Greenhalgh’s metrotome (Fig.

9) is preferred by many. It was,

I believe, the first metrotome in-
vented cutting bi-laterally, and is
very ingeniously constructed. By
it the entire operation is completed
at once. It is easy of introduction,
cuts laterally outwards, and the
extent of the incision can be re-
gulated with great nicety.

Dr. Marion Sims varies the opera-
tion by dividing first one, and then
G“°Mt the ot^er side> of the vaginai portion
dosed. of the cervix with a pair of bent,

Fig. 10.

Dr.

Blades

Expanded.

DISEASES OF WOMEN.

narrow-bladed scissors; tie then presses a narrow-bladed knife-
through the os internum, and cuts from within outwards.

The operation of dividing the cervix uteri is not devoid
of danger; it has, though not in my practice, been followed
by fatal results. I have known very alarming haemorrhage
to occur both at the time, and also some hours subsequently.

You should, therefore, be always prepared for this contin-
gency, and be provided with a solution of the percliloi'ide
of iron in glycerine. With this I was formerly in the
habit of invariably brushing over the divided surface. I
have now given up the practice, because I find if the ope-
ration bo performed in the manner I de- Fig 11.
scribe, there is little, if any, risk of hsemorr-
hage; but should haemorrhage occur, a
pledget of cotton satui’ated with it should be
inserted into the cervix, and the vagina
then plugged. The operation itself seldom
causes pain, and, if the woman be healthy,
the chance of inflammation following is not
great ; still extreme care should be taken
to guard against such occurring, and she
should be kept in bed for several days.

There is often a great tendency in the in-
cisions to unite; to prevent this, Dr. Coglan
has suggested the insertion of a thin roll of
lead ; this answers the purpose very well.

It is sometimes necessary to introduce and
leave in the cervix an expanding spring
stem, as suggested by Dr. Grceuhalgh (Fig.

11), but not unfrequently these precautions
may be dispensed with. Dr. Graily Hewitt

. ,, . o * • Dr. Greenhaloh’&

recommends, with the view ot preventing expanding Stbm.

contraction, and at the same time of keeping the canal

DIVISION OF CERVIX.

63-

straight, that the patient wear for some time subsequently
an ebony stem pessary, a proceeding which in many cases
would doubtless be useful.

Although I have warned you against performing the opera-
tion of dividing the cervix uteri unnecessarily, I feel equally
bound to impress on you the necessity of carrying it out
whenever suitable cases occur in your practice. It is not
merely that by doing so you afford your patient the best
chance of escaping from constantly recurring pain, although
that alone in many cases is a sufficient reason for having
recourse to so safe an operation, but, moreover, long con-
tinued dysmeuorrhcca is likely to produce very grave
consequences. Sterility, metritis, and endometritis ter-
minating in permanent enlargement of the uterus, and
perhaps giving rise, in addition to other distressing symp-
toms, to the occurrence of profuse menorrhagia, may follow,
until the patient, worn out by long-continued suffering, be-
comes a confirmed invalid, or sinks into a state of morose
despondency. Such most likely would have been the result
in the case of the young girl, M. W., on whom you saw me
recently operate. Her sufferings, for several days at each
menstrual period, were extreme; she would roll on the floor
in agony, and this had been the case since the first appear-
ance of the catamenia, three years previously. On examin-
ing her I found the cervix uteri to be abnormally small, and
apparently imperfectly developed. Much difficulty was expe-
rienced in introducing the sound, so contracted was the
cervical canal; and indeed it required the exercise of some
skill to detect the os uteri, it was so exceedingly small. We
found it necessary to dilate the cervical canal in this case,
with a tent of sea-tangle, before attempting to introduce the
metrotome. The result of the operation has been very satis-
factory, for the girl has ever since enjoyed freedom from the

DISEASES OF WOMEN.

excruciating pain she had previously periodically suffered.
I should add that I had tried the effect of a stem pessary
with her before having recourse to the operation, but she
could not tolerate its presence.

LECTURE V.

Menorrhagia — Definition — Causes of— Constitution al and
Local — Subinvolution — Treatment of — Uterine Porte-
caustique — Plugging Vagina.

I propose to-day, gentlemen, to draw your attention to the
subject of menorrhagia; one of the greatest importance, both
on account of its frequency and of the serious consequences
which follow its occurrence.

The term “Menorrhagia,'' strictly speaking, means pro-
fuse menstruation ; the ordinary menstrual period being pro-
longed, or the quantity of blood lost during a menstrual
period of average duration being in excess of what is normal.
In general both these conditions are present, the period being
prolonged, and the quantity of blood lost being excessive ;
but we not unfrequently meet with cases in which a discharge
of blood takes place from the uterus during the interval
between the menstrual periods; to such attacks of haemorr-
hage the term “ Metrorrhagia!' is by some applied.

Let me first of all impress on you that menorrhagia is not
a disease; it is only a symptom of a diseased condition, ■whe-
ther it be of the system at large, or of the organs of genera-
tion only. It is therefore incumbent on you, in dealing with
every case of menorrhagia which may come under your ob-
servation, to endeavour to determine, before you attempt
to treat it, on what the symptom depends. I know of no
affection in the treatment of which professional character is

DISEASES OF WOMEN.

so frequently lost, from want of due care in attending to this
important point.

Thus, within the last few days I was consulted by a lady
who for three years had been the subject of profuse menorr-
hagia, during the whole of which period she had been under
the care of a surgeon in extensive practice. He had pre-
scribed iron and astringents in various forms without benefit,
but lie never once made, or even suggested, a vaginal exami-
nation. I found that the menorrhagia depended on the
presence of a large intra-uterine polypus ; but the discovery
of the cause was in this case made too late. She sank from
sheer exhaustion, and died before the polypus could be re-
moved; had the diagnosis been made but a few months
earlier, a valuable life would have been saved.

Now the causes on which Menorrhagia may depend are
twofold — constitutional and local. I shall speak briefly of
the former class first, and subsequently enter at length into
the consideration of the latter, as being those which are
more immediately within the province of the obstetric phy-
sician. The general constitutional causes which predispose
to menorrhagia are not very numerous, nor is their influence
very distinctly marked. The following are the most com-
mon : —

(1.) Debility arising from any cause, but more especially
if the result of prolonged lactation, is, I think, that to which
menorrhagia is most frequently due. In such cases it often
assumes a very aggravated form. Thus a delicate woman
continues to nurse, although menstruation has re-appeared,
and the patient, weakened by the double drain, rapidly loses
health and strength. In such cases, if nursing be given up
altogether and tonics be administered, of which strychnia
alone or combined with iron, is generally the most useful,
a rapid improvement in the general health, and a marked

CAUSES OF MENORRHAGIA.

•diminution in the quantity lost at each monthly period, often
follows.

(2.) Again, profuse menstruation is seen in young women
-of full habit but of lymphatic temperament. I have met
with several well-marked instances of this; in one especially
the tendency to menorrhagia was so great, and so difficult to
restrain, that on more than one occasion I feared that as a
last resource, I should be compelled to plug the vagina.
This patient was quite a young girl, and looked the picture
of health. In her case, the only remedy which seemed to
exert any decided influence in checking the great loss was
the application of hot water bags to the spine, as recom-
mended by Dr. Chapman — a mode of treatment well worthy
of a trial.

(3.) Again, as age advances and the climacteric period of life
approaches, women are liable to menorrhagia, sometimes of a
very aggravated character. Not unfrequently some months
elapse without the normal discharge appearing, and then it
•comes on so profusely as to give rise to the suspicion that
pregnancy had existed and had terminated by abortion. The
same train of symptoms is not very unfrequently met with
in recently married women; from the non-appearance of the
■catamenia at the regular period, they naturally believe them-
selves pregnant, till, after the lapse of some weeks, they are
undeceived by the return of menstruation in an aggravated
form; in both cases, the cause is probably the same — namely,
temporary congestion of the uterus, and, probably, of the
ovaries. The administration of mild saline purgatives, and
in the former class of cases, if the attacks recur, the exhi-
bition of ergot and strychnia will generally check the exces-
sive loss, or prevent its recurrence.

(4.) Disease of the heart is sometimes attended by menorr-
hagia. rl his evidently depends on congestion, the results of

F 2

DISEASES OF WOMEN.

the retardation of the return of the blood to the right side-
of the heart, and occasionally the loss of blood in these cases
seems to give temporary relief. A good example of menorr-
hagia depending on this canse, was seen in the case of a
woman, long under observation in this hospital, who for
years laboured under mitral obstruction, and in whom the
at tacks of profuse menstruation sometimes assumed an alarm-
ing aspect.

(5.) Analogous in nature to the last mentioned class,
are those cases which depend on chronic hepatic disease
or hepatic congestion. However, as alluded to in another
lecture, hepatic congestion may cause a diminution, rather
than an increased flow, of the menstrual discharge.

(G.) Menorrhagia, too, is met in connection with that form
of renal mischief known as Bright’s disease, due to the blood
being in this disease deprived of its albumen, and conse-
quently in a condition favourable to exudation through the
walls of the capillaries ; but all these affections fall within
the province of my colleagues rather than within mine, and
I must therefore leave you to learn from them the mode
in which menorrhagia depending on these causes should be
treated.

The local conditions causing profuse menstruation are
numerous and very important : they are —

1. Subinvolution of the uterus.

2. Granular ulceration of the os and cervix uteri.

3. Inflammation and congestion of the membrane lining

the cavity of the uterus, and a granular condition of
that membrane.

4. Retention within the uterus of a portion of the placenta

or of the foetal membranes.

5. Congestion of the uterus and ovaries.

6. Polypus of the uterus.

CAUSES OF MENORRHAGIA.

7. Fibrous tumours of the uterus.

8. Inversion of the uterus.

This is a long list, and yet the lesions enumerated in it
are all, with the exception of inversion, of frequent occur-
rence, and all frequently cause menorrhagia. Indeed I think
we should add cancer to it. Some authors, no doubt, object
to cancer being considered as a cause of profuse menstruation,
and in the majority of the cases of this terrible disease, the
discharge to which it sooner or later gives origin, is not in any
way connected with menstruation, and therefore to term it
menorrhagia is incorrect ; but in other cases, especially in
those of epithelioma, menstruation is, in the first instance,
augmented, and the term is then correctly applied. I think
therefore that it is better to speak of cancer, as a possible cause
of menorrhagia. I shall now proceed to call your attention
to each of the foregoing conditions somewhat more in detail.

Subinvolution of the uterus is a far more common cause of
menorrhagia than is generally supposed: indeed, in married
women, or in those who have been at any time pregnant,
profuse menstruation is probably more frequently dependent
on this condition, than on any other.

When we speak of subinvolution of the uterus, we mean
that the process by which the womb regains its original size
subsequent to delivery, or abortion, has been from some cause
retarded or arrested; this process has been termed involu-
tion, and when it is incomplete we talk of the uterus as being
in a condition of imperfect involution, or more commonly, of
subinvolution.

The involution of the uterus should be completed within
a few weeks after the date of delivery. It is one of the most
remarkable phenomena which occur in the human body. The
uterus, immediately before the expulsion of the foetus, mea-
sures about fourteen inches in length, and weighs twenty-

DISEASES OF WOMEN.

five ounces, often, indeed, even more. Immediately after, its
size is reduced to considerably less than one-half its former
bulk, its weight also being proportionately diminished; while,
if the process proceed regularly and unchecked by any cause,
the womb will, after the lapse of five or six weeks, measure
about three inches in length, and weigh but two ounces.
The first step in this process is, that the supply of blood to
the uterus is checked and the circulation of blood through
that organ interrupted, by the contractions of the muscular
fibres of the uterus, a process which commences the moment
labour terminates, and goes on in a more or less painless man-
ner for some days subsequently; while, at the same time,
fatty degeneration and disintegration of tissue, on the one
hand, and absorption on the other, rapidly complete the
work of reducing the uterus to its normal size, and restoring
its compactness of tissue.

But you can easily understand that numerous causes may
interrupt this process; thus in weakly, debilitated women,
the uterine contractions may not be sufficiently powerful to
check the augmented blood supply, consequently the nutri-
tion of the organ may continue almost as active as previous
to delivery, and accordingly the uterus will remain in a state
which may be considered as one of permanent hypertrophy.
Instances of this are very numerous. An exactly similar con-
dition may be brought about in healthy, muscular women if
they leave the recumbent posture too soon after delivery,
and, as many, especially of the lower orders, do, return to their
ordinary occupations, long before the uterus has regained its
normal size. Again, pelvic inflammation in any of its varie-
ties is a common cause; interrupting, and often arresting, the
involution of the uterus. Subinvolution may follow on abor-
tion, even when it occurs in the early months of pregnancy, a
fact you should not overlook; indeed my experience leads me

SUBINVOLUTION OF THE UTERUS.

to think it is much more likely to occur after abortion than
after labour completed at the full term. But from whatever
cause arising, subinvolution sooner or later gives rise to
very troublesome and distressing symptoms of which menorr-
hagia is the most prominent and alarming, the one, too, for
the relief of which we are most frequently consulted.

I cannot better exemplify this affection, than by calling
your attention to the case of C. D., who is still in hospital.
She is forty-three years of age, has had six children. Her
health has never been good since the birth of the last, ten
years ago, shortly after which she noticed that menstruation
was much more profuse than formerly ; for a long time back
each period had lasted for not less than ten or twelve days,
returning after an interval of only a fortnight. On admis-
sion she complained of debility, of great pain in her back,
of irritability of the bladder, and consequent straining and
tenesmus, she also suffered from profuse leucorrhoca. The
effects of this long continued drain was manifest in her
appearance; you must have remarked how perfectly ex-
sanguine she was. I expressed the opinion from the history
of the case, dating as it did from immediately after labour,
that the menorrhagia would probably be found to depend on
subinvolution, and that the irritation of the bladder was re-
flex, depending on an unhealthy condition of the mucous
membrane lining the uterus, which would probably be found
to be rough aud granular; this opinion was confirmed by the
fact, that the os and cervix uteri were healthy, while the
sound proved that the cavity of the uterus was elongated to
the extent of about three inches. I shall by and by refer
to the treatment you saw me adopt in the case; for the
present it is sufficient to say, that she will leave the hospital
in a day or two, after a stay of but three weeks, cured of an
affection of ten years’ standing.

DISEASES OF WOMEN.

Bat the mischief resulting from imperfect involution of
the uterus does not end here, for this abnormal state of the
womb predisposes to the occurrence of that unhealthy con-
dition known as granular ulceration of the os and cervix uteri,
a condition which greatly augments the tendency to menorr-
hagia; thus the two causes which I have placed at the head
of the list may be present in the same patient. The case of
M. F., recently under our observation, afforded a well marked
instance of this. She has had twelve children, and is now
forty-eight years of age. She stated, that ever since the date of
the last confinement, six years ago, menstruation had gra-
dually become more profuse, the flow continuing for a longer
time than usual, the interval between the periods being corres-
pondingly shortened. During the interval she suffered from
profuse leucorrhoea, and was, as a result, greatly debilitated.

On examining her, extensive abrasion of the vaginal por-
tion of the cervix uteri was found to exist, the os was patu-
lous, the lips everted, and the mucous membrane lining the
cervical canal could be seen in a thickened, highly vascular
condition; the uterine sound penetrated to the depth of three
and a-half inches. This patient, too, was discharged, after a
residence of a few weeks in the hospital, perfectly cured.
She occasionally appears among the out-patients, but not
from any return of the menorrhagia. I treated both these
cases alike, with most marked success, by the application to
the interior of the uterus of the fuming nitric acid, in a man-
ner 1 shall hereafter explain at length.

In the foregoing case, subinvolution was manifestly the
primary cause of the menorrhagia, the ulceration being alto-
gether secondary; but often subinvolution exists alone or, on
the other hand, ulceration may exist alone, either condition
being fully sufficient to give origin to severe menorrhagia.
As an instance of the former, the following serves for an ex-

SUBINVOLUTION OF THE UTERUS.

ample: — F. L., tet. twenty-four, a delicate young woman, of
lymphatic temperament, married about a year, had always
menstruated profusely, especially if she took walking exei-
cise, or exerted herself during the flow. She became pregnant
after the occurrence of the second menstrual period subse-
quent to her marriage, but, having imprudently taken along
and fatiguing walk, aborted at the eighth week. The two
subsequent menstrual periods were so profuse as to reduce
her to a state of extreme debility. Ergot, gallic acid, and
numerous other astringents were administered, but they
failed to check the haemorrhage. On examining her, I found
the uterus considerably elongated, the sound passing to the
depth of more than three inches; there was not any ulcera-
tion. The history of the case being altogether against the
supposition of the existence of a polypus, I came to the con-
clusion that the menorrhagia depended on subinvolution; in
fact, that the uterus had never regained its normal size and
tone since the miscarriage which had taken place two months
previously. I therefore decided on carrying out a plan ot
treatment, the value of which you have had, in the wards of
this hospital, repeated opportunities of judging— I mean, the
introduction up to the fundus of the uterus of ten grains ot
the solid nitrate of silver, which is left to dissolve there.
This I accordingly did. It produced considerable pain,
which lasted for five or six hours, but no further unpleasant
results followed. I confined the patient to bed for three
days, and then allowed her to go about. Menstruation ap-
peared at the regular time, and was moderate in quantity.
She became pregnant immediately after, and is now ap-
proaching the full term of utero-gestation.

I wish to call your attention especially to this case, first,
as illustrating the occurrence of subinvolution as a result of
abortion; a fact which, though mentioned by Sir J. Simpson,

DISEASES OF WOMEN.

has been overlooked by many; next, as showing that danger-
ous haemorrhage may result from this condition of the
uterus ; and, thirdly, as proving the excellent results which
follow the treatment I adopted. This point I wish specially
to impress on you. You will find that ergot, gallic acid and
indeed all other medicines, will frequently fail to check
menorrhagia depending on subinvolution, and that you must
have recourse to treatment directed to the uterus itself. You.
must stimulate the organ to set up that healthy action by
which it regains its normal size after pregnancy has termi-
nated, a process to which, as I have already Fig. 12.
told you, the term “involution” is applied.

With this view, I unhesitatingly advocate,
in suitable cases, the adoption of the treat-
ment I practised in this case. The mode of
carrying it out is simple. You introduce
the instrument, which I now exhibit (Fig.

12), into the uterus, just as you would an
ordinary uterine sound. It is Sir James
Simpson’s “Uterine Porte-caustique.” It
consists, as you see, of a hollow silver tube,
in size and shape closely resembling a sound,
and containing a flexible stilette which fits
it accurately. As soon as you are satisfied
that the point of the instrument has reached
the fundus of the uterus, you withdraw the
stilette, and push up by its means, through
the tube, a piece of solid nitrate of silver,
reduced to the requisite size and weight,
until it is fairly lodged in the cavity of the
uterus. In doing this there is but one cau-
tion requisite — namely, that as soon as the
piece of nitrate of silver has reached the ex- porte-^ustique.

TREATMENT OF SUBINVOLUTION. 75-

tremity of the porte-caustique, and before it is finally pushed
out of the instrument (a point you can always be certain
of by observing how much of the stilette remains still
unintroduced), you should withdraw the instrument to the
extent of about half an inch; for, if this precaution be
not observed, it is possible that the nitrate of silver might be
forced into the substance of the uterine wall, instead of being-
left free in its cavity, an accident which, though possible, is
very unlikely to occur.

I have dwelt at some length on this plan of treatment,
because I am satisfied that its value is far from being fully
appreciated. It is looked upon by many practitionei s as
heroic and dangerous. I have pi-actised it freely for several
years, and I believe it to be both simple and safe. I do not
say that it is always sufficient, and that a cure must always
result, but in my hands it has been productive of marked
success, and in no single instance have I known it produce
serious symptoms. That pelvic cellulitis may, under certain
circumstances, follow the introduction of the solid nitrate of
silver into the uterus is quite possible, and I should not at
any time be surprised at its occurrence; but the fear of this
would never deter me from carrying out the treatment, for
an attack of cellulitis is of much less importance than the
continuance of profuse menorrhagia. Although I have seen
cellulitis follow the use of apparently milder astringent
applications, it has not as yet occurred in my practice after
the introduction of the solid nitrate of silver. This treat-
ment is no novelty. Dr. Evory Kennedy, many years ago,,
was in the habit of passing solid nitrate of silver into the
cavity of the uterus; but he did not allow it to remain
there. Subsequently, Sir J. Simpson introduced the method
I now advocate, and invented the porte-caustique.

In the case I have related, I was asked to see the patient

DISEASES OF WOMEN'.

just as the flow which had continued for nearly a fortnight,
ceased to appear, and as a full trial had been given to the or-
dinary methods of treatment without result, and the woman
being in such a debilitated condition that a return of the
haemorrhage might be productive of very serious conse-
quences, I seized the opportunity to carry out the treatment
just detailed. Had I, however, seen her at an earlier period,
I should at once have stopped the loss of blood by plugging
the vagina. This is a mode of arresting the haemorrhage,
wdiich, if properly carried out, is always safe, and, as a tem-
porary means, efficacious. You have seen me practice it re-
peatedly in our wards. Of course, in an emergency, a sponge
or a pocket-handkerchief will answer the purpose; but, when
it can be obtained, nothing does so well as common cotton
wadding. It should be cut in strips, the full length of the
sheet, and two inches wide, the paper to which the wadding
adheres being left attached. These strips should then be in-
troduced one by one, through a speculum, a piece of tape or
twine being attached to those first introduced for the purpose
of facilitating removal, the ends of the string being left out-
side the vulva. As many strips of the wadding as the vagina
will contain are in this manner to be introduced, from four
to six being usually required, according to the capacity of
the vagina. As the strips of wadding are introduced the
speculum should be gradually withdrawn, and, when finally
removed, the finger should be passed into tbc vagina and the
wadding firmly pressed together, when, if it be found that
the vagina is not fully distended with the plug, more cotton
should be introduced. If this precaution be not adopted,
blood is very likely to ooze out between the sides of the
vagina and the plug. Another very good plug is formed by
twisting cotton wool into a rope, and introducing it in the
same manner.

MODE OP PLUGGING VAGINA.

The plug thus formed is easily withdrawn, for if the ends
of the strips last inserted be laid hold of by a pair of dressing
forceps, which are then to be rotated so as to coil the strips
round them, each piece can be extracted in succession without
its breaking, while the ones first introduced are withdrawn,
by means of the strings attached to them.

Any substance left in the vagina rapidly becomes very
offensive; but this can be in a great degree remedied by
smearing the wadding or cotton freely with glycerine. The
plug should in all cases be withdrawn after the lapse of
twenty-four hours; to be replaced for a similar period if the
haemorrhage continues. Should you be unable to obtain
wadding, cotton or tow will answer the purpose very well.
You must, however, be careful to attach a string to each of
the rolls first introduced, and to keep the ends outside the
vulva, or you will experience much difficulty in removing the
plug. This treatment is equally efficacious in restraining
haemorrhage depending on any of the causes I have enume-
rated as giving origin to menorrhagia, and should always be
practised in severe cases.

Some practitioners prefer using the duck-bill speculum
when plugging; but, while its use certainly facilitates the
introduction of the plug, its shape renders its removal, when
once the vagina has been filled with the cotton or wadding,
a matter of great difficulty. In cases of emergency, where no-
speculum is at hand, one maybe extemporized by introducing
the handle of a spoon into the vagina, and with it drawing
back the perineum, or the index and middle finger of the
left hand may be introduced, and made use of to dilate the
orifice of the vagina; for if this be not clone by some means
the introduction of the plug is not only a matter of difficulty,
but will cause the patient much pain. Dr. Greenhalgh, in-
stead of using sponge or cotton, employs three India-rubber

DISEASES OP WOMEN.

balls, which are made in three different sizes and covered
with spongio-piline; one of these is introduced, collapsed, into
the vagina, and then inflated to the required extent; they
are easily introduced and removed, and are worn without
discomfort. Dr. Barnes advocates plugging the os uteri
itself with sea-tangle or sponge tents, in preference to filling
the vagina with the plug. Doubtless, his method is the
most efficacious, but the difficulty of effecting it will render
its general use unpopular.

You are not, however, to infer that all cases of subinvolu-
tion are to be treated on one stereotyped plan, and that in
every case you must have recourse to the introduction of the
solid nitrate of silver. Many cases will yield to milder
though slower methods, especially those in which the mus-
cular tissue of the uterus, being in a very relaxed condition,
permits the organ to remain in a state of extreme engorge-
ment; under such circumstances, the frequent abstraction of
small quantities of blood from the womb (which should be
effected by puncturing the cervix), and the administration of
strychnia and ergot, with or without the addition of iron or
digitalis as the patient’s condition may indicate, will often
prove eminently useful. The abstraction of blood by re-
lieving the engorgement, permits the contraction of the mus-
cular fibres of the uterus and favours the action of the ergot
and strychnia on them. The case of Mrs. M., who for some
time past has been a regular attendant at the out-patient
department, affords a good example of this treatment.
She has had six children, and her illness dates from a
miscarriage which occurred four years ago. She has not
been pregnant since, but has suffered from severe pains
in the back and loins. Menstruation has gradually be-
come more and more profuse, and now lasts for fourteen
days. On examining her, the uterus was found to be much

TREATMENT OF SUBINVOLUTION.

-enlarged, the sound penetrating to the depth of three and a-
balf inches; it was also retroflected, and the cervix was soft
.and engorged. As this patient would not agree to come into
hospital, it was necessary to select a mode of treatment
which would not interfere with her attending to her ordinary
household duties. I accordingly, on May 20th, punctured
the cervix with Dr. Hall’s lancet-shaped knife ; it bled freely.
•On May 23rd she stated that she felt weak, but much easier,
and I introduced a Hodge’s pessary to support the retro-
flexed uterus. From that date, for several weeks, blood was
regularly abstracted from the cervix by puncturing it, and
her condition gradually improved. On the 24th July, I
made a note that the catamenial period which had just termi-
nated, had lasted but seven days, and that the flow was mo-
derate in quantity, the pain in the back much less severe,
and that she felt considerably stronger. During the whole
of this period she had been taking ten drops of the tincture
of the perchloride of iron, three of the liquor strychnise and
twenty of the liquor ergotie, three times a day. On the
22nd of August she reported that another period had just
passed and that it had lasted only three days; the uterus was
now of its normal depth. The simple treatment practised
in this case was eminently successful. The uterus returned
to its normal size and menstruation became regular. Doubt-
less, the treatment extended over four months; but it was
• carried out under the most unfavourable conditions, for
this poor woman continued to perform all her usual house-
hold duties, washing, cooking, &c., for her family during the
whole time. Had I been able to enforce rest in the recum-
bent position, her improvement would have been much more
rapid. In the foregoing case no application was made to
the interior of the uterus, but in the great majority of cases
such is necessary. First, because the mucous membrane

DISEASES OF WOMEN.

lining the cavity of the uterus is generally in an unhealthy
condition, and also because the application of a caustic to
the interior of the uterus stimulates the organ to contract.
Dr. Playfair advocates for this purpose the use of carbolic
acid. I have given this agent an extended trial, and con-
sider it, for general use, superior to perhaps any other. In
old standing cases, or where the lining membrane of the
uterus is in a granular condition, carbolic acid is insufficient,
and it will be necessary to apply the solid nitrate of silver
or the fuming nitric acid. The latter is the agent I gene-
rally employ in such cases, applying it through a platinum
cannula.* The use of carbolic acid, or indeed of any other
iutra-uterine application, should not supersede the local ab-
straction of blood; on the contrary, I recommend you to
carry out both methods at the same time : first applying the
caustic and then puncturing the cervix before the speculum
is withdrawn. Carbolic acid has this advantage over solid
nitrate of silver, or nitric acid, that its use does not necessi-
tate the confinement of the patient to bed. It may be
applied with safety in the cases of hospital out-patients,
or in private patients, whom it may be necessaiy to tieat at
your own houses.

As I do not wish to have to refer again to subinvolution,
I must diverge for a moment from the subject of menorr-
hagia, to say, that though profuse menstruation is nearly
always an early and common symptom of subinvolution of
the uterus, there may be exceptious to this rule, as the follow-
ing case proves: — A young married woman was admitted into
one of our hospitals during the past summer for what was
supposed to be an ovarian tumour. She had been confined
about three months previously of her third child. Haemorr-
hage had followed delivery. She also appeared to have been

* For directions as to the mode of applying these agents, soc Lecture X\ II.

TREATMENT OP SUBINVOLUTION

subsequently attacked by some form of pelvic inflammation.
She recovered slowly and had not been able to nurse. The
lochia ceased to appear during the attack alluded to, and
menstruation had not occurred since delivery. On passing
the hand over the abdomen, a large movable tumour could
be easily felt lying to the left side ; it was very painful to the
touch. After a few days, this woman was discharged from
hospital, her case being considered unsuitable for any kind of
surgical interference. As, however, she continued to suffer
much distress, she presented herself among the out-patients
here, when a careful examination, made with the aid of the
uterine sound, proved the tumour to be the uterus, much
enlarged and elongated; in fact, it was a case of subinvo-
lution with temporary suppression of menstruation. I ad-
mitted her into hospital, and introduced ten grains of nitrate
of silver into the uterine cavity in the manner already de-
scribed. This, as usual, caused some pain for a few hours,
but it had the desired effect. It stimulated the uterus to
set lip the process of involution which the attack of inflam-
mation had arrested, and in a couple of weeks she was dis-
charged, the uterus having almost regained its normal size.
When admitted, the sound penetrated to the depth of five
inches into the uterus.

Although the mode of treatment I have just detailed, and
which you have seen repeatedly carried out in this hospital,
is the one on which you can most rely for the cure of menorr-
hagia depending on subinvolution, I am far from desiring
you to suppose that I advocate its use in all cases. On the
contrary, in general I first try milder treatment. That which
I generally adopt in the less severe forms, of which so many
examples occur among the extern patients, is the application
of a strong solution of carbolic acid (three parts of the acid to
one of spirit), to the iutra uterine surface, carrying it up to the

DISEASES OF WOMEN.

fundus by means of one of Playfair’s probes.* With this, if
congestion exists, I generally couple local depletion, adminis-
tering at the same time such medicines as are known to exert
an influence on the uterus. Of these ergot is the most reliable;
if the patient be anaemic, I usually give ten drops of tincture
of the perchloride of iron and thirty of the liquor ergo tee, with
the addition, in some cases, of three or four drops of the liq-
strychnise three times a day. The addition of ten drops of
tincture of digitalis to the latter prescription sometimes in-
creases its efficacy, but I am reluctantly compelled to add,
that these and similar medicines very often fail to effect the
least good.

* For directions see Lecture XVII.

LECTURE VI.

Menorrhagia continued — Granular Ulceration of Cervix Uteri
— Treatment of- — Granular Condition of Cavity — Treat-
ment of — Mode of Dilating Cervix— Sponge Tents — Sea-
tangle — Barnes’ Dilators — Use of Nitric Add — Curette
— Retained Placenta after Abortion.

In my last lecture I dwelt at some length on the subject of
subinvolution of the uterus, as bearing on that of menorr-
hagia which is frequently associated with it, and I mentioned
that this abnormal condition of the uterus predisposed to
the occurrence of ulceration of the cervix; but ulceration is
•often met with independent of subinvolution, and is by itself
capable of giving origin to profuse menstruation.

Mere abrasion of the lips of the os uteri is not sufficient to
produce menorrhagia, but an unhealthy spongy condition of
the cervix is met with, which bleeds on the slightest touch,
the surface being granular, the os patulous and the lips
everted, a condition quite capable of originating severe men-
orrhagia. Thus I recently saw a young married woman, who
had never been pregnant, who stated that she had become
greatly debilitated by the excessive loss which occurred at
each menstrual period. Ergot and astringents had been freely
administered, and she had been ordered to inject into the
vagina lotions containing alum and zinc; but this treatment
produced no good effect. A vaginal examination proved the
existence of extensive granular disease of the os and cervix

g 2

DISEASES OF -WOMEN.

uteri. Now, in severe cases such as the one I am referring
to, you may rest satisfied that the unhealthy condition of the
mucous membrane extends at least as high as the os inter-
num, and that you will fail to effect a cure unless your
treatment reach every portion of the diseased tissue; there-
fore, with the view of permitting the necessary applications
to be made to the whole extent of the cervical canal, I
commenced my treatment by introducing two tents of com-
pressed sea-tangle, two pieces being sufficient for the object
I had in view, which was not to open the uterus to such
an extent as to enable me to examine its cavity, but only
to permit me to treat the entire of the cervical canal. I left
these pieces in situ for twenty-four hours, and on withdrawing
them, after the lapse of that time, I cauterized freely the
whole of the diseased surface with fuming nitric acid. This
did not cause any pain. On examining the os uteri a few days
subsequently, I found it in a much healthier condition; the
menorrhagia never returned, and although a considerable
time elapsed before the uterus regained a perfectly healthy
state, still the progress of the case was rapid and the cine
perfect, the only treatment subsequently necessary being
the occasional application of a twenty-grain solution of
nitrate of silver to the os uteri, and, at a later period, of
small blisters over the sacrum; finally, not the slightest
trace of the ulceration remained, and menstruation became
in all respects normal.

The foregoing case illustrates perfectly the mode of treat-
ment which, as a rule I adopt. Of course it is not always
necessary to dilate the cervix uteri. If the case be recent
and you can satisfy yourself that the unhealthy condition of
the mucous membrane docs not extend very high, the use of
the solid nitrate of silver, or brushing the part lightly over
with nitric acid, may be sufficient; but in the more severe

GRANULAR CONDITION OP CAVITY.

forms of the disease such treatment will prove to be merely
palliative, and the only effectual means will be found to con-
sist in what I have advocated, or in the use of agents even
more potent than the fuming nitric acid, which, though
it acts rapidly, produces a very superficial slough. In not a
few cases recourse must be had to the potassa c. calce, or to the
actual cautery.* I believe that not a little of the opprobrium
which rests on obstetric practitioners for the length of time
over which their treatment extends, is due to excessive
timidity, and to the use of inefficient remedies.

A condition very analogous to that which we can see in the
cervical canal, occurs also in the interior of the womb, as the
result of congestion and inflammation of the lining membrane
of that cavity; a fact which is often overlooked. Indeed the
majority of systematic writers altogether omit mention of
.it. Dr. Tanner, in his excellent work on the “Practice of
Medicine,” mentions the “existence of an unhealthy pulpy
• condition of the mucous coat” of the uterus as a cause of me-
norrhagia. My o.wn experience leads me to conclude that
while a “pulpy” condition is rare, chronic disease, producing
a rough, granular state of the mucous membrane lining
the cavity of the uterus and giving origin to menorrhagia, is
far from being uncommon. This condition I believe to be
in many respects analogous to that so commonly met with in
the eyelid, and you will fail to cure the menorrhagia which
it causes, until you have destroyed the granulations on the
mucous membrane and restored it to a healthy state, just as
you would fail to relieve the ophthalmia depending on granu-
lar lids until you have cured the palpebral affection. I may
here take the opportunity of laying down a rule, which I ad-
vise you invariably to adopt — namely, whenever you meet
with a case of menorrhagia in an otherwise healthy woman,

* Sec Lecture XVII.

DISEASES OF WOMEN.

Avhich a careful vaginal examination proves not to depend on
ulceration of the os and cervix uteri, on an extra-uterine
polypus, on cancer, or some other evident cause, that you
should dilate the cervix and os internum with the view of
determining what the condition of the interior of the womb
may be. This I hold to be your manifest duty.

I cannot refrain from quoting the judicious remarks of Dr.
Tanner with reference to this subject. He says, speaking of
menorrhagia— Vol. II., p. 301— “When a woman suffers from
repeated attacks of uterine haemorrhage, which can only be
partially or temporarily relieved by rest, nourishing food, and
proper astringents, we may be sure that there is some organic
disease of the ovaries or uterus; and though the cervix and
body feel healthy to the touch, we can be certain that the
bleeding is due to some actual disease ; that it is not func-
tional.” And further on, after enumerating what these causes
may be, he adds — “ There is only one plan of treatment v hick,
can be adopted with a reasonable hope of success, and that is
to dilate the os and cervix thoroughly, so as to permit the
removal of the source of evil.” I fully endorse these obser-
vations.

There are two methods still practised of accomplishing
dilatation of the cervix uteri, the one being with sponge
tents, the other by means of sea-tangle. 1 he former can be
made of any required size ; it is merely necessary to cut a fine
clean sponge into pieces, conical in shape, and of various sizes
and lengths ; for you should always be provided with several
tents of different sizes before commencing the process of
dilatation. You should then wrap each piece as tightly as
possible with fine twine, commencing at the narrow extremity
and winding it on till it reaches the thick end. The pieces of
sponge are next to be immersed in a strong solution of gum
arabic and left in it till thoroughly saturated, and then hung

SEA-TANGLE TENTS.

up to dry slowly. Before these are used the surface should,
after the removal of the twine, be rubbed smooth. A small-
sized tent is to be first inserted, a larger one being introduced
on its removal, after the lapse of from six to twelve hours,
and the process repeated until the cervix is sufficiently
dilated.

I have entirely given up the use of sponge tents ; they are
troublesome to prepare, give rise to a very foetid discharge,
and are further objectionable, because the mucous membrane
lining the cervix sinks into the cells of the sponge, and is
consequently lacerated as the tent is withdrawn, and the
risk of inflammation occurring is thereby greatly increased.
Besides, sponge tents, from their conical shape, necessarily
dilate the os externum the most, often beyond what is required;
while the os internum may not be opened even moderately.
In fine, in my opinion, sponge tents should never be used if
sea-tangle can be obtained.

Tents made of this substance, technically called laminaria
digitata, have been in use for some years for the purpose of
dilating the cervix. The method first adopted wTas to intro-
duce one, which after the lapse of some hours was withdrawn
and another of greater calibre introduced in its place, the
process being repeated till the os internum was sufficiently
dilated. This process was necessarily very tedious, besides
being objectionable in other points of view. It is now given
up, and a modification of it, introduced by Dr. Kidd of this
city, adopted in its place. Dr. Kidd’s method possesses
these three great advantages — it is compai'atively rapid ; is
cleanly ; and lastly, and most important of all, it dilates the
canal equally throughout its whole length, except in some
cases of rigidity of the os internum, to which I shall allude
presently.

Having decided to dilate the cervix, the first step is to

DISEASES OF WOMEN.

expose the os uteri by means of the duck-bill speculum,
next to seize the anterior lip with a small hook, and with it
to draw’ down and steady the uterus, as shown in Fig. 13.
You should previously measure the depth of the uterus, and
have ready several pieces of sea-tangle bougies, each piece
being of at least the length of the uterine cavity. These
you now proceed to introduce ; the main difficulty is in the
introduction of the first piece, the difficulty being greatly in-

Fig. 13.

Polypus (Case op M. D.)
Sea-Tangle in Situ to Effect Dilatation.

creased if the uterus be retro- or anteflected. Short lengths
not being so easily manipulated as long ones, I sometimes,
when difficulty occurs, take an entire bougie and pass it
through the os internum as you w’ould the sound, and then
slip pieces of the proper length in beside it ; for when one
piece has been inserted, it straightens the uterus and serves
as a guide to the others. When several pieces have been in-

SPONGE TENTS.

troduced you can withdraw the long one, or if, before passing
it in, you nick it round at a point corresponding with the
length of the other pieces, you may be able to break it off,
and so avoid the trouble of withdrawing it and substituting
another length in its place. The number of pieces you should
insert varies in each case. If the patient have never been
pregnant and the cervix is rigid, you will not be able to get
in more than three or four ; but, if she have borne children,
and if the cervix be relaxed, you may succeed in introducing
■double that number, or even more, without difficulty.

If a small number only have been introduced, it is better
to withdraw them after the lapse of nine or ten hours, and
introduce a larger number ; but if seven or eight pieces have
been inserted, they may be left for twenty-four hours before
any further steps be taken. The sea-tangle gradually ab-
sorbs moisture from the vagina and uterus, and swells, and
by so doing forcibly dilates the cervix. This of course, causes
pain, which, however, is seldom very severe, and generally
passes off after a few hours. If it continue, I usually direct
a morphia suppository to be introduced into the rectum, or
twenty grains of the hydrate of chloral to be administered at
bedtime.

Dr. Graily Hewitt, who still advocates the use of the
sponge tents in preference to the sea-tangle, states, as an ob-
jection to the latter, that they are liable to slip out. This
certainly is true, if you use the short tents which are sold in
boxes, but if you use pieces of bougie of the length already
specified, and take care that they pass up to the fundus,
there is very little chance of their being expelled ; I have
even on two or three occasions experienced some difficulty
in removing them. This has been the case when the os in-
ternum was so rigid that it prevented the sea-tangle expand
ing as freely at that point as it did in the cavity of the
uterus and in the cervical canal ; and the pieces of tangle

DISEASES OF WOMEN.

being thus constricted in the middle, it was necessary to
press the index finger of the left hand firmly against the lip
of the os uteri, while, with a pair of long forceps held in the
right hand, one piece was seized and slowly extracted. These
are the cases in which, as just mentioned, the whole extent
of the canal is not equally dilated ; then fresh pieces of the
tangle must be introduced and time given to allow of their ex-
pansion before proceeding to explore the interior of the uterus.

You will, however, from time to time meet with cases in
which, although the sea-tangle has expanded to its fullest
extent, still from the size of the tumour, or some other
cause, the os internum is not as large as you would desire.
Under such circumstances I usually complete the process by
the introduction of one of Dr. Barnes’ dilators. These are
India-rubber bags of a somewhat hour-glass, or rather fiddle,
shape. They are made of three different sizes. One end
terminates in a long slender tube, the extremity of which is
furnished with a stop-cock. The dilator is introduced in a
flaccid state into the uterus on the point of a staff or sound,
or held and compressed between the blades of a pair of long
slender forceps, the terminal bulging part being carried by
them through the os internum ; water is then to be gradually
forced in through the long tube just alluded to, and the dilator
left in for an hour or two; by that time it will generally be
found to have distended the canal to a considerable extent.
The peculiar shape of the dilator prevents it, when once it
has been distended, from slipping out of the uterus. Dr.
Barnes originally introduced these bags into practice for the
purpose of dilating the os uteri in cases in which it was desir-
able to induce premature labour, a purpose which they often
serve admirably ; but their use is now further extended, and
w'e employ them occasionally for the purpose of completing
the dilatation of the cervix in the uuimpregnated uterus.

You have had frequent opportunities of seeing the process.

INTRA-UTERINE EXAMINATION.

I have described carried out, and must have noticed the en-
tire absence of unpleasant symptoms, after a proceeding so
apparently severe as the forcible dilatation of the ceirix
uteri. I have therefore no hesitation in recommending you to
adopt this course in your future practice, as being one which
you have seen productive of such good results in this hospital.

I have never, in my own practice, met with an instance in
which unpleasant symptoms followed the introduction of the
sea-tangle, but such have undoubtedly occurred. If, tlieie-
fore, the patient suffer unduly, or that symptoms of inflam-
mation show themselves, it will be your duty to withdraw
the pieces without delay, and for the time at least to give
up all attempts to dilate the cervix.

I have now explained the way in which dilatation of the
cervix is to be accomplished. It remains for me to direct
your attention to the mode in which you are to proceed
when, having withdrawn the sea-tangle or sponge tents, you
desire to clear up any doubt which exists, and satisfy yoiu-
self as to the cause of the menorrhagia.

We have, in the vast majority of cases, to rely for this pur-
pose on the sense of touch alone, and must accordingly pass
the index finger fairly through the os internum till the tip
reaches the very fundus.* To accomplish this by no means
easy matter, it is necessary in the first instance to draw down

* My friend, Dr. Cruise, who has paid special attention to the use of the en-
doscope, has on several occasions made an examination of the interior of the
uterus with that instrument, and is of opinion that in most cases this can
be done satisfactorily. In confirmation of which statement I may refei \ou to
Dr. Cruise’s Paper, in the Dublin Journal of Medical Sciencey VoL LXX\III.r
for May, 1S65, page 333; also to a case recorded by Dr. Hayden, in VoL
LXXX. of the same periodical, p. 497 ; to a paper on Granular Endometii-
tis, by Dr. Churchill, in Vol. I. of the British Medical Journal , p. 2 ; and
to an Essay on the Endoscopic Examination of the Cavity of the Uterus, by
Dr. Pontaleoni, of Nice, in the Medical Press and Circular , for July 14tli,
18(59.

DISEASES OF WOMEN.

and fix the womb; this you effect hy seizing the anterior lip
of the os uteri with a vulsellum, which you intrust to an as-
sistant to Hold, while the fundus should be at the same time
pressed down by your left hand, or better still, by that of
another assistant ; the finger, well oiled, is now introduced
slowly through the os internum and swept round the entire
cavity of the uterus. You will thus detect the existence of
a polypus or a tumour, no matter how small, should either
be present, while the educated finger will recognize the
rough, uneven feel which the mucous membrane, if in an un-
healthy granular condition, conveys to the touch.

I have already expressed my opinion, that this condition
of the interior of the uterus is probably due to sub-acute in-
flammation. This view I believe to be correct ; but be the
cause what it may, the mode of treatment should be the
same, and that is to destroy these so-called granulations
“ and endeavour to excite healthy action in the diseased
part.” With this object, I invariably make use of the strong
nitric acid, applying it with extreme freedom to the interior
of the uterus. In such cases it is necesssary to reach the en-
tire of the diseased surface. I apply the acid by means of a
thin layer of cotton, wrapped firmly round a platinum rod ;
or, if that is not at hand, an iron wire or the stilette of an
ordinary catheter will do. The os is brought into view by the
aid of the duck-bill speculum which protects the posterior
vail from any risk of injury, its concavity being smeared
with lard to prevent the acid from corroding it, while the
anterior wall is guarded by the vulsellum with which the lip
is still firmly held ; the wire armed with the cotton saturated
with the acid, is then passed boldly through the dilated
cervix, swept round the entire of the interior of the womb,
and withdrawn. The canal of the cervix, and the lips of the
os uteri should be protected from the action of the acid.

APPLICATION OF NITRIC ACID.

This can be effected by passing up a glass or a vulcanite
tube as high as the os internum. The cervix having been
previously freely dilated, this can be done w ithout any
trouble.*

In cases when the disease is of old standing, and the
haemorrhage has been severe, I repeat the application, pass-
ing the stilette, armed with a fresh piece of cotton, saturated
with the acid, a second or even a third time up to the fundus,
so as to insure the thorough cauterization of the whole innei
surface of the uterus. As soon as the cauterization has been
effected, a piece of cotton, soaked in water, should be at
once applied to the os, to prevent the vagina being injured
by any acid discharge which might issue from the uterus,
and then the lip being freed from the grasp of the vulsel-
lum, and the speculum withdrawn, the patient is to be placed
in bed.

The subsequent treatment is very simple. Should the
patient suffer pain, which she seldom does to any great de-
gree, I order a morphia suppository to be introduced into
the rectum, but in the majority of cases this is unnecessary.
Indeed, much less pain is caused by this application than by
the introduction of the solid nitrate of silver, though the
latter would seem the milder treatment of the two. This
immunity from pain after application of the acid is very re-
markable.

Having once ascertained the nature of the case, the uterus
should not be again dilated, but it may be, indeed it generally
is, necessary to apply the acid a second time. This may be
done after an interval of a week ; but as a rule I allow a fort-
night to elapse before the re-application. A platinum or
small vulcanite cannula being always introduced, and the
acid or other caustic carried up to the fundus through it;*'

See Lecture XVII.

DISEASES OF WOMEN.

after one or two applications of the nitric acid, cai'bolic acid
may generally be substituted for it.

You can doubtless recall to mind several of the cases
which have been treated by this method during the past
session. The following one, at present in the house, serves
as an example : — J. C., a married woman, a?t. twenty-eight,
admitted 26th Nov., 1870, has never been pregnant. Men-
struation regular, till within the last few months, when she
observed the flow to become much more profuse than for-
merly, and to last for a greater number of days. Latterly,
the interval between each period has been but a fortnight.
She has suffered, and continues to suffer greatly, from severe
pain over the left ovary and in the back. On making an
•examination per vaginam, the os was found to be relaxed and
patulous, the sound penetrated to the depth of nearly three
inches, and the fundus appeared to be slightly enlarged.
The existence of a small polypus or fibrous tumour being
deemed possible, dilatation of the cervix was decided on; five
lengths of compressed sea-tangle were introduced on the morn-
ing of the 3rd Dec., but, on withdrawing them next morning,
the os internum was found still too contracted to admit of
the passage of the finger ; Barnes’ small-sized dilator was
consequently introduced and maintained in the cervix for a
couple of hours. On its removal, I was able to introduce
the finger, and to reach the fundus, but neither polypus nor
tumour could be detected in the uterus. rl lie inner surface,
however, was felt to be rough and uneven; the entire of this
surface was freely cauterized with fuming nitric acid. Ibis
patient was subsequently discharged cured.

Such is the treatment I nearly invariably adopt, circum-
stances, of course, occasionally requiring me to modify it.
Were the patient in a very feeble, debilitated condition, I
should endeavour, in the first instance, to improve her health,

USE OF CURETTE.

restraining the menorrhagia by plugging, by alum injections,
or by hot water bags applied to the spine ; but this treatment
would be altogether palliative, and I should as soon as pos-
sible have recourse to the radical plan I have just advocated.
In many cases, however, of the affection of which I am
speaking it is altogether unnecessary to dilate the cervix,
for when satisfied as to the nature of the case you can apply
nitric acid or any other agent you may select, through my
cannula,* without subjecting your patient to that painful
process, which is only needed when the diagnosis is doubtful.

Two other modes of treatment have been practised to
which it is right I should call your attention; namely, in-
jection into the uterus of astringent or caustic fluids, and
scraping of the inner surface of the uterus with an instrument
called the curette. I do not think the former of these
modes of treatment either safe or satisfactory. Inflamma-
tion of a serious, and even fatal, character, has followed
the injection of fluids into the cavity of the uterus; and I
look on it as a hazardous practice. If any of you, gentlemen,
should be induced to try it hereafter, let me recommend
you, in the first instance, to dilate the cervix, so that the
injected fluid may have a ready means of exit.

As to the curette, its use is, in many cases, a valuable
adjunct to our treatment, but it cannot be relied on alone.
This instrument is intended to detach any soft bodies which
may exist in the interior of the womb; in plain English, the
object is to scrape off its lining membrane, and if this has to
be done almost at random, it is evidently uncertain whether
it effects the object in view or not. Kecamier himself, who
invented it, advocates the cauterizing of the interior of the
uterus with nitrate of silver after the curette has been with-
drawn — a clear proof that the use of the instrument even in

* See Lecture XVII.

DISEASES OF WOMEN.

his own hands proved inefficient. There are just two cases in
which, in my opinion, the use of the curette is justifiable,
namely, for the removal of a small polypus the size of a pea
or bean, which it is difficult to seize with the forceps for the
purpose of twisting off, and yet may be too large to be easily
destroyed with nitric acid, and in those instances, in which,
as the result of long standing disease, the granulations are
of such considerable size that it is doubtful whether the
acid will be sufficiently powerful to destroy them; then
their removal by means of the curette, previous to the free
application of the acid, is justifiable. But in both cases the
cervix should have been previously dilated, and the instru-
ment, if possible, guided along the finger to the required
point.

The retention of a portion of the placenta, or of the foetal
membranes, is too well known a cause of uterine haemorr-
hage to need more than a brief notice. Not long since we
had in hospital a case where this occurred, and to which I
wish to call your attention. This woman was the mother of
five children. Early in February she had a miscarriage, at
about the fifth month of pregnancy. There was considerable
haemorrhage at the time ; the discharge did not entirely dis-
appear for four or five weeks. After an interval of about a
fortnight, a red discharge, which she supposed to be the re-
gular menstrual flow, appeared, and continued, with short
intervals, till the 1st May, when she came under my care.
On examining her, I found the uterus to be much enlarged,
the sound penetrating to the depth of four inches. rl he large
size of the uterus, and the freedom with which the sound ro-
tated in the cavity, induced me to suppose that it contained
a tumour of some kind, and I determined to explore the in-
terior. I accordingly dilated the cervix, and on passing my
finger through the os internum, detected what appeared to

TREATMENT OF MENORRHAGIA.

be a polypus attached by a slender pedicle to the uterine
wall. I seized it with a vulsellum, and using very slight
traction, extracted what proved to be a portion of placenta,
which had been retained in utero for nearly three months,
giving rise to the symptoms I have detailed.

Profuse menstruation, occurring at irregular intervals, is
not unfrequently noticed in women approaching the climac-
teric period, and sometimes assumes an alarming character.
The causes of these attacks are sometimes obscure, but in
many instances they depend on congestion of the ovaries or
uterus, or on hypereemia of both these organs. They are
most likely to occur in women, who, as is often the case at
this period of life, fall into flesh; the attacks are frequently
preceded by a feeling of much discomfort, by headaches, and
sometimes by tenderness on pressure over the ovaries. Dur-
ing the period the excessive loss is best checked by rest, the
application of Chapman’s hot-water bags to the sacrum, and
by the exhibition of ergot. But our main efforts should
be directed to avert a recurrence of the attack. With this
view, the bromide of potassium may be administered, in
thirty-grain doses, for some days prior to that on which the
flow is expected. Not unfrequently, however, although the
patient looks stout and even plethoric, she feels weak, and
complains of fatigue on the least exertion, the pulse is feeble,
the heart’s action weak; therefore, in the intervals between
each period, you should attend carefully to the general
health, see that the diet be nutritious and unstimulating,
that open air exercise be taken, while you will at the same
time administer tonics, of which, arsenic, iron, strychnia, and
digitalis, are pre-eminently useful.

From what I have told you as to the causes on which
menorrhagia depends, you will understand why it is that
astringents, and haemostatics administered by the mouth, are

DISEASES OP WOMEN.

so frequently ineffectual in checking the haemorrhage. You
are not, however, to suppose that they are useless. On the
contrary, they are frequently productive of much benefit
and generally are valuable adjuncts to our surgical treatment.
In cases of profuse menstruation depending on subinvolution,
you will often find ergot check temporarily the discharge. I
generally give the liquor ergo tie, in half drachm or even
drachm doses every four hours. If the patient be anaemic,
I usually administer along with it, ten drops of the tincture
of the perchloride of iron ; and, unless its exhibition is from
some cause specially contra-indicated, add from three to five
drops of the solution of strychnia to each dose of ergot, and
am satisfied that it greatly increases the peculiar action of
that drug on the uterus. I have also tried this combination
with advantage in cases of post partum luemorrhagc. You
have had an example of its effects in the case of the patient,
who was admitted for profuse haemorrhage coming on three
weeks after abortion at the fourth month, which I believed
to have been kept up by the retention of the placenta, and
may have remarked that each dose of the ergot and strychnia
was folio-wed by sharp uterine pains, resulting in the ex-
pulsion of the placenta. I recommend you to try this in
your future practice. I am also at present, as you are
aware, testing the efficacy of the hypodermic injection of
ergotine in the treatment of these cases. Gallic acid too,
alone, or in combination with ergot, is an admirable medi-
cine, and often produces excellent effects. I usually give
ten-grain doses of both. The mineral acids and acetate of
lead, are extensively prescribed in cases of menorrhagia.
They are, however, very unreliable agents.

LECTURE YII.

Polypus — Varieties of— Cystic — Mucous — Fibrous — Symptoms
of— Operation for Removal of— Advantages of Steel Wire
Modification of Gooch's Cannula— Fibrinous and Pla-
cental Polypi.

In the preceding lecture, I have spoken of those forms of
menorrhagia which depend on, or are caused by, an abnor-
mal or diseased condition of the uterus or of its lining mem-
brane ; to-day, I have to call your attention to an affection
as important as any of the preceding, one, too, of frequent
occurrence, and which almost invariably gives rise to pro-
fuse menstruation. I allude to polypus, which may be
defined as the result of an hypertrophy of some portion
of the uterine substance, which, taking the form of an
out-growth, becomes in time a distinct tumour attached
to the wall of the uterus, either by a base of considerable
extent, or more frequently, by a well-defined pedicle. These
growths are met with of all sizes and shapes, sometimes as
little stunted bodies only the size of a pea or small bean ;
sometimes as large tumours occupying the entire cavity of
the uterus as large as that organ should be at the fourth or
fifth month of pregnancy; but more commonly they are seen
of intermediate size.

Occasionally the uterus seems to resent the presence of a
polypus which has been developed within its cavity, and by
contractions, similar to those of labour, expels it, and thus
causes it to assume the form of an extra-uterine tumour ; a

H 2

100

DISEASES OF WOMEN.

process which is evidently Nature’s attempt, often a success-
ful one, to effect a cure. When this takes place, and an
intra-uterine polypus expelled from the uterus reaches the
vagina, the haemorrhage it has given rise to is usually
checked, or may possibly cease altogether. But, in addition
to those of intra-uterine origin, polypi may grow from the
cervical canal, just within the os uteri, or spring from the
vaginal surface of the uterus.

Three varieties of polypi are met with ; namely, the cystic
or glandular, the mucous, and the fibrous. The cystic or
glandular polypus, as the name indicates, generally presents
to the eye the appearance of a cyst. These polypi are soft,
pearl-coloured bodies, composed of an albuminous, gelatinous
fluid enclosed in a delicate membrane. They appear some-
times to be simply enlarged or hypertrophied Nabothian
glands, but are occasionally new growths. I pointed out to
you an example of the latter form in one of the out-patients
a few days ago, in whom a polypus grew from the lip of the
os uteri ; it was the size of, and not very dissimilar in ap-
pearance to, a grape, and had not caused luemorrhagc. When
I attempted to seize it with the forceps, it broke, and dis-
charged its contents. I cauterized its point of attachment
freely with nitric acid, and when the woman presented her-
self again, after the lapse of a few days, no trace of this little
polypus remained. In none of the cases of cystic polypi,
which have come under my observation, have they been of
greater size than a hazel nut or grape, nor am I aware of any
instance in which they were attached high up in the uterus.
They nearly invariably grow from some portion of the cervi-
cal canal. These polypi are always sessile, that is, grow
directly from their point of origin without the intervention
of a pedicle ; twro or more may, and frequently do, occur at
the same time. When once detected, they are easily de-

MUCOUS POLYPUS.

101

■stroyed, cither by pressure or by torsion. If situated within
the cervical canal, they generally give origin to a glairy dis-
charge, and nearly always cause htemorrhage.

The mucous polypus may spring from any portion of the
mucous surface of the uterus; but its favourite seat seems
to be the cervical canal, and it may not unfrequently be seen
projecting from the mouth of the womb, as a small tumour
of a bright pink colour, which bleeds on the slightest touch.

These growths, when of cervical origin, seldom attain a
large size. The largest of this variety which has come under
my observation occurred in a woman, the wife of a cabman.
I saw her about twenty-four hours after delivery, and
found a polypus, of the size of an orange, hanging partially
out of the vagina. It was attached by a long and very
slender pedicle to the cervix uteri, the point of attachment
being just inside the os. The midwife who attended this
woman assured me that her labour had been in all respects
easy and natural, and that she did not detect the polypus
till after the expulsion of the placenta. Its vitality had
evidently been destroyed by the pressure to which it had
been subjected during the passage of the child’s head
through the vagina; for when I saw it, it already exhibited
signs of decomposition. This patient stated that lia\ ing
lifted a heavy weight when in the third month of pregnancy
she felt something give way internally, and immediately
afterwards perceived a tumour at the vulva. Profuse
haemorrhage followed, which, however, soon subsided, and
the tumour receded. During the remainder of pregnancy
she enjoyed good health, and, excepting that when fatigued
she noticed something appear at the vulva, she was not
conscious of the existence of anything abnormal. A polypus
of such size as this springing from the cervical canal, is,
however, rare.

102

DISEASES OF WOMEN.

Another example of a large mucous polypus occurred in
one of our out-patients, an unmarried woman, aged twenty-
four. Persistent haemorrhage, which all astringents failed to
check, compelled- me to make a vaginal examination, and I
discovered one of these polypi, nearly an inch and a quarter
in length, but not much thicker than an ordinary quill,
hanging out of the os uteri. In the great majority of in-
stances, however, the mucous polypus does not attain a
fourth of that size. These small ones are nearly entirely
composed of a soft gelatinous structure. They are highly
vascular, and often give rise to severe hajmorrhage quite out
of proportion to the size of the tumour. They are generally
attached to the canal of the cervix by a slender pedicle, and
their vitality is very easily destroyed. It is not at all un-
common to meet with several small mucous polypi in the
same patient; occasionally they are of a denser texture, a
greater proportion of fibro-cellular tissue entering into their
structure, and when this is the case they are more likely to
attain a large size.

Once detected, the l’emoval of these mucous polypi of cer-
vical origin are a matter of great ease. This can be effected
either by torsion, or by means of a pair of curved scissors ;
or better still, by snaring them with a loop of thin iron
wire, severing the attachment either by twisting it or by
using an 4craseur. Doubtless, it seems almost unnecessary
to use an 4craseur to remove so small a body, but it is by
no means easy to twist off these little growths; it is often
imperfectly done, and as a consequence the operation has
to be repeated, and thereby much suffering entailed on the
patient. I now always use a wire for the purpose of re-
moving them; indeed I have seen such profuse haemorrhage
follow the excision of even very small polypi, that I do
not think I shall ever again use a knife or pair of scissors for

MUCOUS rOLYPI.

103

the purpose. In all cases, their point of origin should be
cauterized with nitric acid. When they project from the
os uteri, this is all that has to be done, but sometimes they
lie higher up in the cervical canal, and then you have to
dilate* the canal before you can reach them. This proceed-
ing may of itself be sufficient to effect a cure, for so readily
are they destroyed by pressure, that instances are not of
infrequent occurrence, in which menorrhagia having led the
physician to dilate the cervix in order to explore the uterus,
he has, when this dilatation was effected, found no morbid
structure, the sea-tangle having destroyed by its pressure
the polypus to which the menorrhagia was due. The fact of
a polypus not being discovered in any particular case, is,
therefore, no proof that one may not have existed.

But mucous polypi are occasionally met with springing
from the fundus of the uterus; then their removal is a
matter of more difficulty, for the uterus must be dilated
throughout its whole extent, the polypus seized, its attach-
ment severed, and nitric acid freely applied to the inte-
rior of the womb. Here is a specimen of a mucous polypus
which I recently removed from a patient in this hospital;
it is very large, being, as you may see, the size of a goose’s
egg. The patient from whom this polypus was removed is
unmarried, aged twenty-six years. A year and a-half ago
she presented herself among our out-patients, and stated
that of late menstruation had become so profuse as to debi-
litate her greatly. This, with some leucorrhcea, was the
sole symptom she complained of. Suspecting the existence
of a polypus, I instituted a vaginal examination; but, as the
uterus proved to be of normal size, I did not consider
myself justified in exploring its interior, and contented
myself with the administration of ergot and iron. This
treatment at the time proved of use, and for a time we lost

104

DISEASES OF WOMEN.

sight of her, hut not longsince she again presented herself, and
stated that her improvement had been but temporary, that
she soon relapsed into her former condition, and, indeed, had
gradually become worse. The flow, at the time she pre-
sented herself, having lasted for quite three weeks, she was
now admitted into hospital.

On examining her, a large, soft intra-uterine polypus was
found to exist. Its lower segment projected through the
os uteri, which was dilated to the size of a five-shilling-piece.
The sound penetrated into the uterus to the depth of four
inches. This patient was placed under the influence of
chloroform; a wire was passed round the pedicle, and the
tumour removed without difficulty; for, though its size was
so great, it being eleven inches in circumference, its texture
was so soft that it was easily severed from its attachment
and drawn through the os uteri. The lower portion of the
tumour exhibited well-marked signs of incipient decomposi-
tion. This case illustrates three clinical facts of considerable
value. First, that these polypi may give rise to no symptom
save profuse menstruation; secondly, the comparative rapi-
dity of their growth ; and lastly, their tendency to cure by a
process of loss of vitality. I may further point out that it
also illustrates a fact not sufficiently dwelt on, that intra-
uterine polypi, in the majority of instances, occur in women
who have never been pregnant.

The fibrous polypus is, I think, more frequently met with
than either of the other varieties, and is more difficult to
treat. The exciting cause and mode of growth of these
tumours is still far from being clearly understood. We only
know that, as a rule, they spring from the uterine sub-
mucous tissue, are composed of firm fibro-cellular elements,
and are invariably covered with mucous membrane. In
fact, they are “out-growths of and from the substance of the

SYMPTOMS OF POLYPUS.

105

uterus, the mucous membrane and the muscular and fibrous
tissue of the uterus growing in a variety of proportions into
its cavity” (Paget). These polypi are generally supplied
■with numerous blood-vessels, which, however, are seldom of
any magnitude. They are met with of all sizes, nor does the
amount of haemorrhage necessarily bear any proportion to
the size of the tumour; they may be small and sessile, but
more commonly are connected to the wall of the uterus by
a well-defined pedicle, which, however, varies greatly in
thickness and length. We seldom find more than one
fibrous polypus in the uterus at the same time. I am
aware, however, that there are exceptions to this rule; thus
I had the opportunity recently afforded me by my friend Dr.
Kidd, of seeing a patient from whom he had removed nine
fibrous polypi at one operation.

The fibrous polypus generally grows from the fundus of
the uterus, though examples from time to time occur of its
being attached to other portions of the uterine walls. But
no matter where attached, its course is the same — the poly-
pus gradually enlarges, while the whole of the uterus,
stimulated apparently by its presence, increases in bulk and
density, till, not unfrequently, Ave are enabled to feel the
organ above the pubes. If not interfered with, and if the
polypus be pedunculated, it is possible that in time the
uterus may expel it, and thus it may become extra-uterine,
and even appear at the vulva. Such a course, however, is
far from usual. In general the haemorrhage, Avhich almost
invariably accompanies this affection, runs down the patient,
and compels her to seek for relief long before that stage can
be reached; or, if she fail to obtain the requisite aid, con-
signs her to a premature grave.

The symptoms marking the occim-ence of polypus are
threefold; namely, haemorrhage, leucorrhoca, and pain. Hae-

106

DISEASES OF WOMEN.

morrhage is, I may say, invariably present. The patient
generally first notices that the menstrual flow is more pro-
fuse than formerly; then that its duration is prolonged, and
that leucorrhooa occurs in the interval; pain above the pubes,,
and over the ovaries, is also generally complained of. No'
age, from puberty upwards, possesses an immunity from this'
disease. Here, on the table, are specimens of four intra-
uterine fibrous polypi removed from patients aged respec-
tively twenty-four, forty-six, thirty-five, and fifty-three years,,
the two former being from unmarried, the two latter from-
married, women.

The first specimen is the one you saw recently removed from

M. D , who has just been discharged from this hospital.

Her case is a very interesting and instructive one. She is
aged but twenty-four years, and is unmarried. Three years
ago she began to notice that the catamenia were more pro-
fuse than natural ; they have continued so ever since. About
a year ago she, for the first time, experienced pain in the
left side of the abdomen, which at one point was tender to
the touch; lying on that side, too, caused her much distress,
but she was still able to hold her situation as housemaid.
On the 8th of August last the catamenia came on suddenly,
and so profusely as to cause faintness. On admission into
hospital a day or two subsequently, there was little or no
discharge present, but the haemorrhage had been of so alarm-
ing a character, that I deemed it necessary, though she was
an unmarried woman, to institute a vaginal examination.
The vagina was moderately relaxed, the cervix appeared to
be healthy, but the body was anteflexed and heavy. The
sound penetrated to the depth of three inches. The cause
of the haemorrhage being still uncertain, I proceeded, in ac-
cordance with my invariable rule under such circumstances,
to dilate the cervix, and, with some difficulty, succeeded in

REMOVAL OP POLYPUS.

107

introducing several pieces of sea-tangle. On attempting to
withdraw these after the expiration of twenty-four hours, I
experienced great difficulty; for the os internum was so rigid,
that it had prevented the tangle expanding at that point, to
the same degree it had in the cavity of the womb, and each
piece, when finally extracted, was found to be constricted in
the centre. Having succeeded, however, in removing them,
a larger number were introduced, and next day, I found the
cervix was freely dilated throughout its entire length. On
introducing the finger into the uterus, I detected a polypus
of considerable size, attached by a short thick pedicle to
the anterior wall of the uterus near the fundus ; the appa-
rent anteflexion of the uterus being due to the fact, that the
anterior wall was bulged outwards by the polypus, as shown
in Fig. 13 (p. 88). To effect this examination, the anterior
lip had to be seized by a vulsellum, and the uterus drawn
down in the manner described in my last lecture.

Fig. 14.

The position, size, and shape of the polypus being thus
ascertained, the next step was to remove it. I shall detail to
you exactly how this was effected in the case I am referring
to, as it will serve as a description of the mode in which
the operation should be performed in all similar cases.

The uterus having been drawn down as low as possible by
means of the vulsellum, which was fixed in the anterior lip,
the index finger of the right hand was introduced till its tip
touched the polypus. Another strong vulsellum, such as
that shown in Fig. 14, was then taken in the left hand and

108

DISEASES OP WOMEN.

guided up to the polypus along this finger, and the tumour
firmly grasped by it. The latter instrument being intrusted
to an assistant, the anterior lip was freed from the one by
which it was held. This was done in order to give more room
in the vagina, but unless the polypus be a firm one, the hold
we have obtained on the lip of the womb should not be let go.

Steady traction was now exerted on the polypus by means
of the vulsellum with which it was grasped, and it was drawn
down as low as possible in the pelvis. A long Ecraseur, made
much on the pattern of that suggested by Dr. Braxton Hicks
(Fig. 15), and armed with a strong iron wire, was then in-
troduced, the wire being passed over the handles of the
vulsellum so as to surround them. The extremity of the
Ecraseur, kept in contact with the finger, was guided up to
the polypus, and the wire, after some difficult manipulation,
was slipped over the upper surface of the polypus. The

point of the ecraseur was then pressed firmly against the
lower edge of the pedicle, and kept in as close contact as pos-
sible with its point of attachment to the uterine wall. This
is a matter of great importance, for unless the point of the
instrument be kept in the position described, the wire will
not be drawn close to the base of the pedicle, and thus the
whole of the tumour will not be removed. The ecraseur was
then slowly but steadily worked, the pedicle cut through in
a few minutes, and the polypus, still held by the vulsellum,
extracted (Fig. 16).*

* The operation as here described was first practised by Dr. G. H. Kidd, of
Dublin. See Dublin Journal of Medical Science for February, 1S09.

Fig. 15.

Wire Ecraseur.

INTRA-UTERINE ECRASEUR.

109

The whole of the inner surface of the uterus was then
brushed over with strong nitric acid, with the double inten-
tion of preventing haemorrhage, and of destroying any un-
healthy condition of the mucous membrane of the uterus,
should such exist. The patient was, of course, under the
influence of chloroform during the operation. She recovered
without the least drawback, was allowed to walk about the
ward in a few days, and has since menstruated normally.

Fig. 1G.

Ecraseur Apm-ied for Removal of Polypus.

This operation, though it is so easily described, is most diffi-
cult to perform. The polypus is quite out of sight, and can
with difficulty be touched by the finger, even when drawn
down with the vulsellum; then the space, in which you must
have at least two instruments as well as your finger, is so

110

DISEASES OF WOMEN.

contracted that one sometimes almost despairs of being able
to carry the wire round the tumour; and even when this is
accomplished your wire may break, and all the trouble has
to be gone over again. This accident occurred twice in the
case of the woman from whom the largest of the tumours
I now show you was removed.

In the case I have just detailed I used a strong iron wire,
and though the base of the polypus was three-quarters of an
inch in diameter, it was sufficient for the purpose; still, as
already mentioned, a single iron wire cannot be relied on if
the pedicle be thick. I formerly used a cable of wire twisted
tightly together, but some of the strands are liable to give
way, and the ends become entangled in the parts, or, getting
twisted round the extremity of the ecraseur prevent it
working; therefore I have discarded it, and now always em-
ploy a strong steel wire,* such as that used for piano strings
except when the pedicle is very slender. For introduction
of the steel wire into practice for this purpose we are in-
debted to Dr. Kidd. Although very stiff, it is hardly more
difficult to manipulate in the uterus than the flexible iron
wire, for the loop, which is always constricted in passing
through the os, expands as the result of its own elasticity on
reaching the cavity of the uterus.

The extreme difficulty of encircling an intra-uterine poly-
pus with a wire or chain, induced Dr. Marion Sims to invent
an intra-uterine ecraseur, which is a marvel of ingenuity but
very complex, and in practice has proved a failure. I tried

* Dr. Braxton Hicks, who was, I believe, the first to advocate the nse of the
wire cable, still gives it the preference, and is of opinion that a cable of
well-annealed steel wire, not too smoothly coiled, answers much better than a
singlo strong wire. He lays much stress on having the head of the cScraseur
slightly curved, so that there may be no angle on which the wire can cut, and on
having the eye very much rounded at the edge, so that the cable may not be
frayed.

author’s ecraseur.

Ill

it in two cases, and found it impossible to adjust, and con-
sequently have been compelled to abandon its use.

Influenced by this difficulty, I was led to cousider whether
a less complicated instrument could not be devised, which

would enable the operator to at-
tain the desired end. I accord-
ingly had this ecraseur (Fig. 17)
made by Weiss. It differs from
an ordinary long wire ecraseur
only in having the end modified, so
as to allow of the passage through
it of two slender silver tubes, iden-
tical with those so well known as
“Gooch’s cannulas.” These (a, a)
armed with a wire ( h , b) of any
strength, can be passed with ease
up to the base of the polypus;
they are then to be separated, and
while one is held firmly, the other
is carried round the pedicle.
This can always be accomplished
when a silk or hempen ligature is
used, but it is very difficult indeed,
to carry a stiff wire round a large
tumour with them. However, I
have done it, and cases from time
to time occur in which thismethod
proves useful. Having once got
the wire round the tumour, the
cannulas are to be passed through
the openings (c, c) in the ex-
tremity of the ecraseur; the
Ecraseur is then to be pushed

Fig. 17.

112

DISEASES OF WOMEN.

up, guided by the cannula;, till it comes in contact with the
pedicle of the polypus, the cannulse can then be withdrawn,,
and the wire being attached to the ecraseur at d and e, the
operation is completed as if we were using an ordinary wire
ecraseur. This is, in point of fact, an adaptation of the
cannulse of Gooch to the ecraseur.

There has no greater advance been made in uterine surgery
than in the treatment of intra-uterine polypus. Before the
method of dilating the cervix uteri was introduced, it was
impossible to diagnose their presence with any degree of
accuracy. We might suspect their existence from the occur-
rence of haemorrhage, and of uterine leucorrhoea, but nothing
more; now, to use Dr Marion Sims’ language, “We can
determine with the minutest accuracy not only their presence,
but the size, shape, position, relations and attachments of all
such tumours,” and, by means of the ecraseur, remove them
in a short time without pain to the patient, who is under the
influence of chloroform, and without any great risk to her life.

But a fibrous polypus may spring from the vaginal portion
of the cervix, as well as from the interior of the uterus; its
removal is then comparatively an easy matter; for, unless
the bulk be very great, the chain or wire of an Ecraseur can
be carried round it without much difficulty, and its separa-
tion accomplished in a few minutes. These polypi, as well
as those of intra-uterine origin which, having been expelled
from the womb, have become vaginal, do not bleed so freely
as those contained within the uterus. Dr. McClintock, in
his work “ On Diseases of Women,” relates a striking example
of this. He removed an enormous fibrous polypus which
weighed thirty-four ounces, from the vagina of a woman aged
fifty, and yet for two years previously she had not had any
red discharge.

Here is a specimen of a remarkable form of fibrous polypus.

FIBROUS TOLYPUS.

113

You see it has a double attachment to the uterus. This
patient was admitted into hospital suffering from profuse
menstruation. On making a vaginal examination, a large,
firm, smooth tumour was found projecting through the os
uteri into the vagina. Anteriorly, and rather to the right
side, this tumour could be traced up to the os, with the
anterior lip of which it was continuous, and presented the
character of a sessile polypus springing from the margin of
the os uteri and lower segment of the cervical canal. The
finger, passed up over the posterior surface of the polypus,
could not reach the upper margin of its attachment. The
sound penetrated to the distance of nearly three inches be-
yond the furthest point the finger could reach in this direction.

The patient having been etherized, the tumour was drawn
down by means of a vulsellum, and, with some difficulty, I
succeeded in carrying a steel wire, attached to a long ecra-
seur, over the posterior surface of the polypus. The wire,
however, broke before constriction had proceeded to any great
extent, the attachment being evidently very dense and
thick. A strong annealed wire was now in like manner
carried over the tumour, but with no better success — it also
broke ; and a third attempt, with a very strong steel wire
(piano string), resulted in the breaking of the ecraseur. The
attempt to remove the tumour with the ecraseur having thus
failed, I determined to detach it, if possible, by means of a
pair of curved scissors. This proved to be a matter of much
difficulty, the tissue being extremely dense ; but, after the
expenditure of considerable time, I succeeded in cutting
through the portion attached to the anterior lip. When,
however, this was accomplished, I Avas disappointed at find-
ing that the true pedicle had not yet been reached, but that
the tumour sprang from a point in the uterine wall much
higher up. The severance of the anterior attachment having

114

DISEASES OF WOMEN.

given more room, and the tumour being well drawn down by
means of the vulsellum, I at once, proceeded to sever the
pedicle. This was accomplished partially with the scissors
and partly with a scalpel. Considerable haemorrhage fol-
lowed, to restrain which I applied the actual cautery, freely,
to the bleeding surface ; but, as it still continued, a pledget
of cotton soaked in glycerine and saturated with the per-
chloride of iron, was inserted within the os uteri, and the
vagina plugged with cotton wadding. pjg. ig_

Some hours subsequently, violent
and incessant vomiting set in. This
I attributed to the irritation caused
by the pressure of the plug, for on
its removal the vomiting ceased.

No further unpleasant symptoms fol-
lowed, and the patient made a rapid
and good recovery.

The tumour, on examination, proved
to be a fibrous polypus. It weighed
half a pound, its greatest circum-
ference was seven inches, that of the
true pedicle, four inches. The most
remarkable point connected with
the case was that the polypus had
two attachments. It appeared to
have been doubled back on itself, Fibrous Tumour

WITH

the point of the tumour having Double attachment.
become so firmly and evenly united to the right side of
the os uteri, that it was continuous with it. This con-
dition is represented in the annexed woodcut (Fig. 18).
This union, I presume, must have occurred as the result of
some inflammatory attack which took place when the point of
the tumour had reached the os uteri, and that as the tumour

FIBRINOUS POLYPI.

115

subsequently grew, the descent of the point being arrested
by its union to the lip of the uterus, the central portion was
forced downwards, and thus became the most depending
part. The length of the polypus, when in utero, measured
from its pedicle to the most depending point, was five inches,
but, when removed and unfolded, it measured seven and a-
half inches.

This woman was in a very anaemic condition, and the heart s
action extremely feeble. These circumstances induced me
to select ether as the anaesthetic to be employed, and the
result was very satisfactory. There was no excitement, strug-
gling, or vomiting. The pulse never failed, nor, during the
whole of the long period she was under its influence — for the
operation occupied an hour and a-quarter — was it necessary
to withdraw it. The sickness which subsequently followed,
I do not attribute, for the reason already stated, to the
effects of the ether.

In addition to the three classes of polypi I have just
spoken of, and which are undoubtedly out-growths from some
portion of the uterine substance, two others are recognized by
pathologists, to which I must allude. The one is termed the
fibrinous, and is looked upon by some authorities as the result
of abortion. “ The embryo having been extruded, the re-
mains of the ovum left behind, form with the extravasated
blood, the foundation of a fibrinous polypus;” others believe
these tumours to be “ metamorphosed and adherent coagula
of retained menstrual blood.”

The possibility of the remains of the placenta being
capable of giving rise to polypoid bodies in the uterus has
also been advocated, especially by Dr. Stadfeldt, of Copen-
hagen, from a translation of whose paper by Dr. W. D. Moore,
in the Dublin Quarterly Journal for November, 1863, I
have quoted the foregoing extracts, the perusal of which

i 2

lie

DISEASES OF WOMEN.

will amply repay any of you who may desire to become better
acquainted with this subject. Dr. Stadfeldt does not believe
that those small portions of the after-birth which nearly
always remain after the placenta has been detached, and
which usually come away with the lochia, are capable, even
if retained, of giving origin to these growths, but only when
portions varying in size “from that of a walnut to that of a
goose egg or larger, and which contain one or more colytodons
of the placenta” are left behind, and remain firmly attached
to the uterine wall.

Ably adduced, however, as are the arguments of Dr. Stad-
feldt, I am not satisfied that his views arc borne out by the
facts brought forward in support of them. They amount to
this : that in four cases large portions of the placenta were
found after death adherent to the uterus in women recently
delivered ; the longest interval which elapsed between delivery
and death being but four weeks; in his other cases but a few
days intervened. With similar instances every obstetric
physician is familiar.

In the case related at the conclusion of my last lecture, I
removed a portion of placenta which had been retained in the
womfc for nearly ten weeks after delivery, and which doubt-
less was during that time gradually being loosened from its
attachment to the uterine wall, and its connection was pro-
bably only completely severed by the traction I made use of.
That it was still connected with the uterus we may, I think,
safely infer from the fact that the mass was not in any degree
decomposed; but the persistence of vitality in a portion of
placenta adherent to the uterus is a very different thing from
its development into a polypus.

LECTURE VIII.

Fibrous Tumours— Definition of— Varieties of— Sub-perito-
neal— Sub-mucous — Intra-mural — Enucleation Inti a-

uterine Injections — Influence of Free/nancy — Spontaneous
C ures.

I shall proceed to-day, gentlemen, to direct your attention
to the subject of fibrous tumours of the uterus, a subject of
even greater importance than that of polypus, which was last
under our consideration, and unfortunately oftener beyond
the reach of surgical interference.

A fibrous tumour may be defined as, a growth composed of
fibrous tissue, identical in structure with that of the uterine
wall, but “disconnected” from it, being in general surrounded
by a capsule of dense fibro-cellular tissue, which “is pecu-
liarly dry and loose, so that when one cuts on the tumour it
almost of itself escapes from its cavity” (Paget, Surgical Pa-
thology). This fact of the fibrous tumour of the uterus
being by means of its capsule disconnected from the sur-
rounding tissue, distinguishes it from the ordinary fibi'ous
polypus ; a distinction which cannot often be made during
life. The annexed woodcuts, copied from Paget, illustrate
the difference between these two growths; the one (Fig. 19)
being a section of an uterine out-growth or polypus, the other
(Fig. 20) of a uterine fibrous tumour; the former being “con-
tinuous,” but the latter “ discontinuous,” with the substance
of the uterus, although both in outward appearance are very
■similar.

118

DISEASES OF WOMEN.

It would be quite impossible in the brief limits of a clini-
cal lecture to enter at any length into the pathology of a
subject so extensive as that of fibrous tumours of the uterus.
I can only glance at a few of the leading characteristics, re-
ferring such of you as desire further information on this
interesting subject to the works of Paget, West, M'Clintock,
Matthews Duncan, and others.

Fig. 19. Fig. 20.

Uterine Out-growth. Uterine Fibrous Tumour.

(after Paget).

Fibrous tumours are met with of all sizes, from that of a
grain of shot upwards; those of large size being by no means
of unfrequent occurrence, while cases are on record, in which
they have attained a size greater than that of the uterus at
the full term of pregnancy, and a weight of 70 lbs., or even
more. Again, they may be solitary, but usually two or more
are present in the same patient ; they may spring from the
peritoneal surface of the uterus, and can be felt through the
abdominal wall ; they may grow from the sub-mucous tissue
of the uterus, or, finally, be developed within the walls of the
organ. Consequently, fibrous tumours are spoken of as be-
longing to one of three classes — namely, sub-peritoneal, sub-
mucous, and intra-mural, according as they are found to
grow in one or other of the situations I have designated.

The extra-uterine or sub-peritoneal, being in general be-
yond the reach of treatment, must be dismissed after a brief

FIBROUS TUMOUR.

119

notice. They vary in size and appearance in even a gieatei
degree than either of the other varieties; sometimes being
numerous, small in size, and sessile, giving the surface of
the uterus a nodulated appearance; or, on the other hand,
attached by a pedicle which is sometimes short and thick, as
shown in Fig. 21, or at other times, so long and slender as

Extra-Uterine Fibrocystic Tumour.

to permit the tumour to float, as it were, free in the abdomi-
nal cavity, and finally even dissever itself from all connection
with the womb, and possibly become attached to some othei
portion of the peritoneal surface. W hen sub-peritoneal
fibroids are pedunculated they sometimes descend into the
pelvis, and then, by their pressure on the neighbouring organs,
give rise to most distressing symptoms. When this occurs
the patient’s sufferings are sometimes very severe, incessant
desire to micturate, or total inability to pass water, being
frequently experienced. Of course, it is impossible to give
relief unless the tumour be raised from its position and re-
placed above the brim. This is always a matter of great

120

DISEASES OF WOMEN.

difficulty, sometimes an impossibility. The tumour inva-
riably lies in the posterior cul cle sac, between the rectum
and the uterus, occupying much the same position which the
impregnated uterus does when retroverted. With the view of
raising it above the brim, Dr. Kidd has adapted to such cases
the method suggested by the late Dr. Halpin, of Cavan, for
restoring the uterus to its normal position 'when retroverted
during pregnancy. He introduces one of Barnes’ largest-sized
India-rubber bags into the rectum, and gradually distends
it with water by means of a syringe, while, at the same time,
steady pressure is made with the finger onthetumour through
the vaginal wall. In this way, you will occasionally succeed
in raising the tumour, and making it slip up into the false
pelvis, unless indeed the case be of long standing, and it be
bound down by adhesions ; should such exist, your efforts
will be not only useless, but injurious.

Sub-peritoneal fibrous tumours do not necessarily give
origin to menorrhagia; indeed, as a rule, they do not seem
to influence menstruation at all. Thus, in the case delineated
in Fig. 21, the catamenia were quite regular. These tumours
also generally spring from the posterior surface of the uterus
or from the fundus. This, however, is far from being always
so; for, in the patient from whom the drawing (Fig. 21)
was made, the tumour grew from the anterior wall. This
case was interesting too, as affording an example of that form
of the disease termed fibro-cystic, in which a cyst is developed
within the structure of the solid tumour.

The patient was under the care of my friend, the late Dr.
Morgan, in Mercer’s Hospital, through whose kindness I had
an opportunity of seeing her. She appeared to be about
thirty-five years of age, was married, but had never been
pregnant. She stated that two years ago she detected a
small, hard, movable tumour in the left iliac region; that a

FIBROUS TUMOUR.

121

year subsequently she perceived what she supposed to be
another distinct tumour in the right side; the latter was
however but a projecting portion of one large central growth,
which had steadily increased till she had attained the size ot
a woman near the full term of pregnancy, but she did not
think that for the last few months she had become larger.
Menstruation appeared regularly at intervals of three weeks,
fluctuation was everywhere very distinct, and there was uni-
versal dulness on percussion. On making a vaginal examina-
tion, the tumour could be easily felt blocking up the brim of
the pelvis. The anterior lip of the os uteri, which was greatly
hypertrophied, projected into the vagina, the uterus lying
quite behind the tumour. The diagnosis of the uterine cystic
disease was made, and all idea of surgical interference was
given up. This patient subsequently died of an attack of
acute peritonitis, and we had an opportunity of verifying our
diagnosis. The tumour, which was of enormous size, con-
sisted mainly of an immense cyst; it sprang from the anteiioi
and upper surface of the uterus, being connected to it by a
short, thick pedicle. The woodcut, which accurately repre-
sents both the size, shape, and position of the tumour, was
taken from a drawing made by my friend and former pupil,
Dr. Hamilton Moorhead.

The sub-mucous, pedunculated, fibrous tumour is, prior to
its removal, in no way distinguishable from, and is to be
treated in a manner identical with the ordinary fibrous poly-
pus of which I have already spoken. I shall not, theiefoic,
allude to it any further, but shall proceed to the con-
sideration of the third, and most important variety of these
tumours.

Intra-mural, or as they are sometimes termed parietal,
or interstitial fibrous tumours, are of frequent occurrence.
They differ from the sub-peritoneal in two important features

122

DISEASES OP WOMEN.

—namely, that they nearly always cause menorrhagia, also
almost as invariably cause pain, frequently of a very severe
character, which is aggravated on the approach of each men-
strual period, and stimulate the uterus to enlarge; effects not
usually produced by the sub-peritoneal variety. Thus, in the
case just alluded to, though the tumour weighed upwards of
11 lbs., and was at least 2o inches in circumference, the
uterus was of nearly its normal size and shape; -while the
presence of even a very small intra-mural tumour has been
known so to stimulate the womb, that it has grown to a
length of five or six inches, while its walls have attained a
thickness of an inch or more. Dr. West, in his work On
Diseases of Wcfnen, mentions a case illustrative of this fact.

The growth of an intra-mural fibrous tumour is sometimes
very slow. In a case at present under my observation, and
in which the womb has attained a length of five inches, no
appreciable change has taken place during a period of two
years. On the other hand, the tumour sometimes steadily

increases in size, and then one of three results must occur

either, it will bulge out the peritoneal surface of the uterus,
and possibly may become a sub-peritoneal tumour; or it may
continue to grow in the substance of the uterus, the whole of
the organ enlarging as the tumour increases; or it may pro-
ject into the uterine cavity, carrying before it a covering of
the muscular tissue of that organ. It is easy to conceive how
this latter process, if continued, may result in the formation
of an intra-uterine tumour, connected with the wall by a
pedicle, consisting of muscular tissue continuous with that
of the uterus and of the mucous membrane covering it; and
that this pedicle may in time elongate, and as it lengthens
become more slender, till finally it passes out of the uterus ;
or even, the pedicle giving way, may be expelled from the
vagina. Nearly all writers, with the exception of Dr. Mat-

FIBROUS TUMOURS.

123-

thews Duncan, admit the possibility of such an occurrence.
He thinks that the uterine wall never elongates before the
true intra-mural tumour, but that the tumour is expelled
bare into the uterine cavity, enucleation of the tumour, a
process to which I shall have to refer by and by, having
taken place spontaneously. However, one thing is quite
certain, that these growths frequently present themselves-
as well-defined tumours projecting into the cavity of tlio

uterus.

Here is a specimen of a tumour so circumstanced ; you sec
that it is connected to the uterine wall by a very extensive
attachment, the circumference of the base being greater than
that of any other portion of the tumour. It was taken from
the body of a patient who recently died in hospital. She
was a married woman, aged fifty-three. About five years
ago she ceased to menstruate, but after a considerable in-
terval, again observed a sanguineous discharge to appear.
This at first recurred with tolerable regularity, then gradually
became more and more profuse, till finally it was continuous.
Some months ago, she perceived a tumour m the abdomen,
which at one point, on the left side, was extremely tender to
the touch; she also experienced constant pain in, and was
unable to lie on, that side. When admitted into hospital
she was in a very amemic condition.

On passing the hand over the abdomen, a large turnout
could be felt lying rather to the left side, which, as I have
already mentioned, was at one point very tender to the touch.
On making a vaginal examination, this tumour proved to be
the uterus greatly enlarged. The sound passed to the depth
of five inches. I at once proceeded to dilate the cervix with
sea-tangle, on withdrawing which, this large tumour was de-
tected projecting into, and filling up the whole cavity of, the
uterus. The patient’s condition rendered it absolutely nc-

124

DISEASES OF WOMEN'.

■cessavy that its removal should be immediately attempted.
I endeavoured to accomplish this, with Marion Sims’ intra-
uterine ecraseur, but, as stated in a former lecture, I found
that instrument quite unsuitable for the purpose. I then
tried an ordinary wire ecraseur, and succeeded in ensnaring
the tumour, but the wire (an iron one) broke. Three times
I succeeded in encircling the tumour with the wire, but the
strain to which it was subjected was too great, and on each
occasion it broke. As the patient was now much exhausted
I desisted from any further attempt; besides I hoped that the
gicat pressure to which it had been subjected, might have
beeu sufficient to destroy the vitality of the tumour and that
it would slough off. Matters went on very well for three
days; indeed on the third day she expressed herself as being
■quite well. There was not any haemorrhage ; she had no
pain on pressure, and the pulse was quiet ; but, on the night of
the fourth day, she was suddenly seized with a violent rigor,
complained of intense pain over the abdomen, sank into a
state of low, muttering delirium, and finally died comatose.

On opening the abdomen after death hardly anv trace of
peritoneal inflammation presented itself, but on raising the
omentum, that point on the fundus of the uterus which, as
previously noticed, had been so excessively tender to the
touch, was found to be in a condition of actual mortification.
•On opening the uterus this enormous tumour was seen; it
was nearly five inches in length, and its base where the liga-
ture had surrounded it, measured nine inches in circum-
ference.

i his case fairly illustrates the risk which must be incurred
in the attempt to remove fibroid tumours having extensive
attachments to the wall of the uterus; the mortality attend-
ing the operation, in such cases, being, as far as my cxjieri-
■ence goes, very high indeed.

FIBROUS TUMOURS.

125“

The body is the usual seat of intra-mural fibroids, but
they may be developed in any part of the uterine wall. Thus-
I recently removed one which was embedded in the anterior
lip of the os. The patient was an unmarried woman, aged
about thirty. She stated that for some months past she had
suffered much discomfort from a sense of weight and fulness
in the vagina, and that recently she perceived a tumour
protrude from the vagina, which receded when she lay down,
but always reappeared when she walked about. Menstrua-
tion continued perfectly normal.

rig 22.

Intra-mural Fibroid of Cervix.

On examination, an ovoid mass of the size of a hen’s egg,
was seen projecting from the vagina, its long diameter being

126

DISEASES OF WOMEN.

parallel with the vulva. The protrusion consisted of the
anterior lip of the uterus, which was elongated and thick-
ened, the uterus itself being drawn down by the weight of
the tumour till it rested on the perineum, the os uteri being
•close to the vulva. rl he condition of the parts is correctly
represented in the annexed woodcut (Fig. 22.)

The diagnosis of a fibrous tumour embedded in the an-
terior lip of the uterus having been made, I determined to
amputate the elongated portion of the cervix, electing to do
so by means of the galvanic knife, hoping by that method to
lessen the risk of haemorrhage, which the thickened and
hypertrophied condition of the part led me to think would
be likely to occur — an opinion which the event verified. The
apparatus employed was Grenet’s. The galvanic knife con-
sisted of a loop of platinum wire about half an inch in length,
connected by means of the ordinary wire conductors with
the battery.

The cervix measured 3| inches in circumference at the
point selected for amputation. The great thickness of the
tissue to be divided, and its extreme denseness, rendered the
operation very tedious. The cauterization was sufficient to
prevent any serious haemorrhage occurring; still two arteries
had to be ligatured.

On subsequent examination, the amputated lip was found
to contain a perfect fibrous tumour enclosed in its capsule.

Very frequently, however, fibrous tumours appear as mere
protuberances, bulging out the uterine wall, as is shown in
Fig. 23. Such tumours as these cannot be removed with an
ccraseur, and yet you cannot leave them alone, for health is
undermined, and life itself frequently endangered by the
haemorrhage arising from their presence. The treatment to
be adopted in such cases necessarily divides itself into the
palliative, and the radical; the former consists of restraining

FIBROUS TUMOURS.

127

the profuse flow, which occurs at each menstrual period, by
plugging the vagina, as recommended in a former lecture, and
by the administration of haemostatics, such as gallic acid,
alum. &c., while ergot, alone or in combination with per-
chloride of iron, is often useful. But this plan of treatment
is irksome to the patient, and can only be looked on as a
means of delaying the fatal results, which, if the haemorrhage
continue, ere long must follow unless more energetic means
be adopted.

Medicines without number have been administered with
the view of causing the absorption of fibrous tumours of the
womb. I have tried fully and freely most if not all of
them, and believe them to be of no use. It would be
waste of time for me to go through the long list of drugs
which have been recommended in these cases. I do not
wish to deter you from trying them in your future prac-
tice; they will probably do' no harm, but I think I can pro-
mise that they will effect little good. For myself I have lost

Intra-mural Fibrous Tumour (after Sims).

128

DISEASES OF WOMEN*.

all faith in the resolvent powers of medicines of this class, in
the disease at present under consideration.

The very limited good produced by medicines has induced
obstetric surgeons to adopt energetic measures for the treat-
ment of intra-mural fibroids; no less than six methods hav-
ing been recommended, and practised with the view to the
radical cure, of these embedded fibrous tumours. They are —
1st, incision of the cervix uteri; 2nd, incision of the tumour;
3rd, incision into the tumour and destruction of a portion of
its tissue, a process to which the term gouging has been ap-
plied; 4th, enucleation of the tumour; 5th, avulsion, or the
forcible tearing away of the tumour from its attachment ;
6th, the formation of a slough, in the tumour and interven-
ing portion of wall of uterus, produced by the use of the
actual cautery.

Incision of the os was first practised in this city by Dr.
M'Clintock.* This operation has been founded on a theory
of Mr. Baker Brown’s, according to which, “ the division of
the os and cervix uteri, permits the fibres of the body of the
uterus to contract upon the contained tumour, and thereby
to compress the vessels and prevent haemorrhage.” Whether
this be the true explanation or not, one thing is quite certain,
that the operation is often followed by good results, and in
the case of very large tumours, which are contained within
the uterus, and when the cervix is thinned and spread over
them, is fully justified.

The incision of the tumour has bee.n practised by Dr.
Atlee, in America; by Dr. Tracy, of Melbourne, and others
with success — a success which is probably due to the fact
that the vitality of these tumours is nearly, if not altogether,
destroyed by the incisions having divided their capsules; for
the fibrous growth itself is endowed with but a very low

* Diseases of Women, p. Hi1.

ENUCLEATION.

129

degree of vitality. I have not met with a suitable case in
which to try this treatment, but I certainly should not hesi-
tate to do so where the frequent recurrence of profuse hae-
morrhage in a patient in whom an intra-mural tumour existed,
which I could not control by other means, would demand it,
and where, on dilating the cervix, too great a depth of the
uterine wall was not found to intervene between the opeiator
and the capsule 5 for if this condition existed I would deem
an incision dangerous, as being liable to be followed by ex-
cessive, possibly fatal, haemorrhage.

Thus, in the case of a young woman, recently under my
care, in whom a fibroid of the size of a cocoa-nut was em-
bedded in the uterine wall, we found, on dilating the ceivix
and introducing the finger, that the tumour bulged the
uterine wall altogether outwards, the cavity of the uterus
being hardly at all encroached on. On endeavouring to seize
the tumour with a vulsellum, it became evident that the
uterine wall alone was grasped, and that the greater portion
of the muscular tissue of the uterus intervened between the
inner surface of the organ and the tumour. The substance
of the uterus itself appeared to be soft, and in an unhealthy
condition. I consequently dreaded lest an incision made to
so great a depth might not result in dangerous htemorrhage,
and therefore deemed it right to cease from any further at-
tempts at the surgical removal of the tumour, contenting
myself with cauterizing the inner surface of the uterus freely
with the fuming nitric acid.

This woman has gone to the country to recruit her general
health; when she returns, I intend giving a full trial to the
hypodermic injections of ergot, practised in the mode I
shall presently explain.

Enucleation, that is the cutting down on and division
of the capsule, the tumour being then seized and turned

130

DISEASES OF WOMEN.

out of its capsule, is an operation suggested by a consi-
deration of one of the pi-ocesses by which Nature occasion-
ally effects a spontaneous cure: the capsule and investing-
covering of the tumour becoming thinned at one point by a
process of absorption, the contained tumour is then pushed
out by the contractile power of the uterus, and so finally ex-
pelled. Enucleation is advocated by Dr. Matthews Duncan,
with his usual ability. He also practises the operation of
avulsion; that is the seizure of the tumour with a strong
vulsellum, and forcible avulsion of it from its attachment.

Avulsion is adopted by Dr. Duncan in cases in which spon-
taneous enucleation has already partially begun, or where
that process, having been artificially commenced, has ad-
vanced to a certain extent. He considers it to be the proper
practice in those cases of fibrous tumours in which the
patient’s life is in great danger, and which medical treatment
is unable to avert. I am not able to speak from personal
experience as to the value of the operation, but you will find
full details of Dr. Duncan’s views on the subject in the twelfth
volume of the Edinburgh Medical Journal. I am equally
without experience as to the merits or demerits of “ gouging;”
but I am of opiuion, that surgical treatment has been some-
times carried too far in dealing with fibrous tumours.

There are less heroic modes of treatment, I would have you
bear in mind, and under certain circumstances practice,
before having recourse to surgical measures. One is the injec-
tion, after 'previous dilatation, of tincture of iodine, or of the
liquor of the perchloride of iron, into the uterine cavity.
This practice is warmly advocated by Dr. Routh, of London,
and, if the cervix and os internum be first dilated, so that
the injection may have a free and rapid exit, I do not think
that it is likely to be followed by unpleasant symptoms. My
friend, Dr. M‘Clintock, informs me that he has recently in-

ERGOT HYPODERMICALLY.

131

jected tincture of iodine with marked success, in the case of
a lady, whom I had an opportunity of seeing with him, and
in whom alarmingly profuse menstruation, which he ascer-
tained to be dependent on the presence of a large fibroid,
occurred from time to time.

Dr. Matthews Duncan has recorded two cases in which he
successfully restrained dangerous haemorrhage, depending on
the existence of a tumour in the uterus, by the injection, in
each case, of one drachm of the liquor ferri. perchloridi, by
means of a hollow sound, into the cavity of the womb. In
his cases the cervix does not seem to have been dilated, a
precaution I should always adopt.

The hypodermic injection of ergot has, for some years
past, been extensively practised for the control of various
forms of haemorrhage, and with considerable success; latterly
the same treatment has been adopted with the view of check-
ing ioost parlum haemorrhage with equally good results, the
main objection to its use being, that troublesome sores are
apt to form at the site of the operation Dr. Hildebrandt* has
published the particulars of eight cases in which he has prac-
tised the sub-cutaneous injection of ergot in the treatment
of fibrous tumours of the uterus. He comes to the con-
clusion that ergot thus used is a powerful agent. In one
case, a tumour which reached above the umbilicus dis-
appeared; in a second a tumour, extending as high as the
false ribs, descended below the umbilicus, and in four other
cases, in which the treatment was otherwise less complete,
there was an amelioration of the general and local condition.
According to him, ergot thus employed, rectified menstrua-
tion in almost all the cases, rendering its recurrence regular,
less profuse, and above all, less painful. It is true, as Dr.
Hildebrandt remarks, that it is not easy to state precisely

* Gazette llebdomadaire de Medicine el de CKirurgie, VoL IX., page 4-13.

K 2

132

DISEASES OF WOMEN.

how the ergot acts; but he adds that it is very likely that,
as a result of the contractions produced by the ergot in
the nutritive vessels of the tumour, and in consequence of
the compression exercised in all directions by the contractions
of the uterine walls, the nutrition of the tumour is impeded,
and that in time fatty degeneration and absorption follows.
It is probable that intra-mural tumours arc more easily
acted on than sub-peritoneal. Dr. Hildebrandt’s formula is:
watery extract of ergot, three parts; glycerine, seven parts;
and distilled water, seven parts. Such a solution is better,
in his opinion, than an alcoholic one, as its use does not
produce so much pain, and is not so liable to be followed by
the formation of abscesses. He recommends that the in-
jection should be made in the lower segment of the abdo-
minal walls, between the umbilicus and pubis, and says,
that after the operation the patient may be allowed to walk
home. There is no doubt but that an aqueous solution is
less liable to be followed by unpleasant consequences than a
spirituous one.* I adopted Dr. Hildebrandt’s formula, and
injected from three to five drops of the liquid extract
of ergot on each occasion; at the same time, I must caution
you against looking on the hypodermic use of ergot, espe-
cially if the needle be inserted, as Dr. Hildebrandt advises,
above the pubes, as a perfectly safe procedure. Encouraged
by his experience I injected, as you may remember, about
three minims of the liquid extract of ergot under the skin
of the abdomen, in two of our out-patients a few days since,
and allowed them to walk home. Both suffered severely:
one was confined to bed for three days subsequently, so
intense was the pain she experienced, and so considerable
the inflammation which ensued. I should not recommend
you to employ the hypodermic injection of ergot, unless the
patient could remain at rest.

* I now omit the glycerine. See pago 139

ERGOT HYPODERMICALLY.

133

I have given the hypodermic injection of ergot a full
and fair tidal in several cases, both in hospital and private
practice The details of the following cases will enable
you to judge for yourselves as to the results which may
be expected from this mode of treating uterine fibroids.
The cases are doubtless too few in number to lead to any
definite conclusion, but I think they establish two facts :

1st. That the hypodermic injection of ergot is most effica-
cious in restraining uterine haemorrhage depending on the
presence of a fibroid; and, 2ndly. That the treatment is not
altogether unobjectionable. In three of my cases trouble-
some abscesses formed sooner or later, in two of the patients
giving rise to considerable constitutional disturbance, while
hi a fourth I was obliged to abandon the treatment in con-
sequence of the excessive pain following the injection. It is
worthy of special notice, however, that since I omitted the
glycerine, no abscess or sore followed the injection.

Case I.— M. H , aged 41, suffered from very profuse

menstruation, the periods being invariably ushered in by
intense pain, so intense that for a long time previous to her
admission into hospital she had been in the habit of taking,
nightly, large doses of tincture of opium. On admission a
tumour, as large as the foetal head at full term, could easily
be felt in the abdomen. The sound penetrated to the depth
of 4J inches, and after a careful examination, the diagnosis
of fibrous tumour of the uterus was made. As the case
seemed a very suitable one in which to try the effects of the
hypodermic injection of ergot, I at once commenced this
treatment, using for the purpose the extractum ergotce liqui-
dum (B.P.) in the proportion of three parts of the extract to
seven of glycerine and seven of water, this being the foimula
recommended by Prof. Hildebrandt. The first injection of
twenty minims of the solution just named, containing about

134

DISEASES OF WOMEN.

Uliiiss of the ergot, was made on the 1st November, during
a very profuse menstrual period. In about three hours it
markedly checked the flow, but the pain caused was so in-
tense that I did not venture to repeat the injection for several
days; the flow, I should add, entirely ceased on the second
day after the injection. On this occasion, and on all the
subsequent ones, the fluid was injected behind the great
trochanter, the needle being made to penetrate into the sub-
stance of the glutsQus muscle, on either side alternately, to the
depth of upwards of half an inch, previous experience having
proved to me the correctness of the observation made by Dr.
Keating, in The American Journal of Medical Science, that
the tendency to inflammation occurring after the injection of
ergotiu, is much lessened by passing the needle through the
cellular tissue into the substance of the muscle.

The second injection was made on the 9th November, and
the third on the 16th. From that date the injections were
repeated on every second or third day, and once or twice on
two days in succession, according to the intensity and dura-
tion of the pain produced by the operation, until fifteen in-
jections had been given. Two abscesses then formed on the
site of the two last injections, and these became so very pain-
ful and troublesome that the treatment had to be discon-
tinued for three weeks.

The effects hitherto observed were these : — 1st. Very in-
tense and long continued pain always followed the injection.
The duration of the pain was from five to twelve hours, after
the lapse of which time, it gradually subsided, leaving her
greatly exhausted. She was unable to sleep during its con-
tinuance. I was therefore obliged, except on two occasions,
to allow at least forty-eight hours to elapse between the
injections. 2ndly. The duration of the catamenial periods,
which on admission had been fourteen days, was, on the

ERGOT HYPODERMICALLY.

135

recurrence of the first period after the ergotin had been
injected, reduced to four days ; on the second to two days,
and on the third to one day. 3rdly. The periods were ren-
dered free from pain ; formerly the pain at these times
had been very intense. It is necessary to add that the two
last injections were not made in accordance with the rule
I had laid down ; namely, that the needle should penetrate
deeply into the substance of the muscle, for during my
absence the needle was introduced on one occasion over
the head of the femur, and on the other occasion very near
the crest of the ilium.

It was not until the 5th January, 1874, that the abscesses
and sinuses resulting from the injection of the ergot, had
sufficiently healed to permit a resumption of the treatment.
On recommencing I resolved to employ a different prepara-
tion of ergot, and accordingly procured some of “Wigger’s
pure ergotin.”

This, instead of being a liquid, is a granular substance,
and very insoluble; I injected two grains of it on the 5th.
The catamenia had appeared two days previously; the flow
lasted four days without pain. I consider this satisfactory
state, however, as due to the previous treatment. On the
10th, having passed the sound into the uterus, the flow re-
turned and continued for four days more; and again, after
an interval of but four days, the discharge reappeared, con-
tinuing for six days, the hypodermic injection being repeated
daily. On the 2nd February I made the following note
“The hypodermic injection of the Wigger’s ergotin did not
cause any pain, but it seems to be inefficacious, for the pro-
fuse metrorrhagia has returned.”

I now decided on trying Bonjeau’s ergotin; this is a thick
fluid, easily mixable with water. I injected TT\_iv of it dis-
solved in ll\_xx of water. This caused some pain, less, how-

136 DISEASES OF WOMEN.

ever, than that produced by the English preparation. The
injections were from this date continued regularly, Tffiv of
ergotin being injected every second day.

March 11th — Catamenia came on after twenty-four days’
interval, accompanied with intense pain, which was only re-
lieved by the hypodermic injections of morphia. The flow-
ceased on the seventh day. I believe Bonjeau’s ergotin to
be less efticacious than the English preparation, but on the
other hand to be much less irritating.

Shortly after the last date this patient was compelled to
return home. She resides in a very remote part of Ireland,
and I have been unable to learn anything of her present
state.

Case II. — This case is of little practical value, excepting
so far as it illustrates the difficulty of carrying out the treat-
ment of fibrous tumours by the hypodermic injection of
ergot.

A. M. , aged 25, a pale, unhealthy-looking woman, six

months married, presented herself among the out-patients cf
the Adelaide Hospital. She stated that of late she was hardly
ever free from profuse and weakening haemorrhage. Her ap-
pearance fully confirmed this statement; she was evidently
anaemic and in very bad health. On examination a large in-
terstitial fibroid was diagnosed. In her case I commenced
treatment by injecting four grains of Bonjeau’s ergotin, dis-
solved in fifteen minims of water. The fifth injection, how-
ever, was followed by the formation of a very painful and
troublesome abscess, and on recovering from it she left hos-
pital, nothing would induce her to permit the injection to be
repeated. I think it probable that the rapidity with which
abscesses formed in this case, may be accounted for by the
fact that the woman was evidently ill-fed, and in a thoroughly
bad state of health.

ERGOT HYPODERMICALLY.

137

Case III. — An unmarried lady, aged 48, came under my
care in February, 1874, at the termination of a very profuse
menstrual period. She stated that eight years previously,
she had detected a tumour in the abdomen, which had ^gra-
dually increased to its present size. Menstruation had, for
manv years, been profuse, becoming markedly so during t m
last two years, with occasional hemorrhagic discharges dur-
ing the intervals. Never, however, till recently, of sufticien
severity as to cause alarm. She had always been more or
less of an invalid, and was, moreover, the subject of we
marked cardiac disease. The tumour was very large-it
reached nearly to the umbilicus. The sound penetrated to
the depth of five inches. The diagnosis of fibrous tumour
was made. When I saw her first she was in a state of grea
danger. The excessive loss of blood had reduced her to a
condition of extreme debility. She fainted constantly; the
pulse was small, feeble, and intermittent. Under treatment
she gradually improved; but being convinced that a recur-
rence of the profuse loss would probably prove fatal, I deter-
mined to try the effects of the hypodermic injection of
ero-ot, not, however, without considerable hesitation, for, in
he”- debilitated state, I dreaded the formation of abscesses,
which my previous experience had shown me were so prone

to occur. .

I should add that at this time the periods recurred at in-
tervals of not more than fourteen days, and that during this
interval, she was seldom free from a slight red discharge.

The first injection of two grains of Bonjeau’s ergotm was
made on the 20th February, the same formula being used as
in the former case. The needle was inserted behind the
great trochanter, and made to penetrate to the depth of at
least an inch. No pain followed. From that date to the
20th of March, the injection of the Bonjeau’s ergotin was

138

DISEASES OP WOMEN.

continued with tolerable regularity on every second day;
occasional intermissions, however, occurred, when, from a feel-
ing of excessive debility, arising generally from the heart’s
action being more than usually irregular, she seemed unable
to bear the pain, trifling though it was. Five grains of the
ergotin were, during this period, injected on each occasion.
The haemorrhage returned on the 20th March so very pro-
fusely, that I was obliged to plug the vagina; the interval
had, however, lengthened a little.

As no marked benefit had resulted from the injection of
Bonjeau’s ergotin, I now substituted for it a solution of
Wigger’s ergotin. Of this, I injected about four grains
on, as nearly as possible, every second day till 15th April.
The catamenia had appeared on the 9th April so profusely,
that I was again obliged to plug the vagina. The injection
of Wigger’s ergotin did not cause any pain; but the flow
on this last occasion was, if anything, more profuse than be-
fore; therefore, after a trial extending over full three weeks,
I relinquished it, and again used the solution of Bonjeau’s
ergotin. After it had been employed for some days, one
impi-ovement in her condition was noticed, the slight red
discharge, which had never been absent for more than a few
hours together, ceased to appear; the interval between the
period also was prolonged, the flow not appearing on this oc-
casion till the 8th May- — an interval of a whole month. The
loss on the 10th was very heavy, but the period lasted only
five days. This result I looked upon as most satisfactory,
but at this juncture, the seat of the last injection inflamed,
and after much suffering, an abscess formed, and though
opened in good time, a troublesome fistulous sore resulted,
which healed up very slowly. The treatment, therefore,
was necessarily suspended.

On the 22nd she unfortunately caught cold, and suffered

139

CHANGES IN FIBKOUS TUMOURS.

from an attack of rheumatic fever. This attack greatly re-
duced herstrength, and shortly after she died rather suddenly,
with the symptoms usually attending the formation of a clot
in the pulmonary artery. There can he no doubt but that
the injection of Bonjeau’s ergotin in this case was productive
of marked good. The sanguineous discharge which had been
for a very long time constantly present disappeared; the inter-
val between the periods lengthened from fourteen to twenty-
four days, and the periods themselves became correspondingly
shortened; but, notwithstanding every possible precaution
an abscess formed.

The results so far obtained discouraged me greatly , and
for a time I discontinued treating fibroids by the hypodermic
injection of ergot, but Dr. Hildebrandt’s recent statements
as to his continued success, induced me to give it a further
trial. I resolved, however, to omit the glycerine from the
solution, and to use the extractum ergotce liquidum, B.P.,
dissolved in water alone, and since doing so, I have not been
once troubled by the formation of abscesses and sores, which
in my former cases had given rise to such pain and suffer-
ing. The following is a brief abstract of some of the cases

I have recently treated : — Case IV. Mrs. , a widow, aged

38, never pregnant, the subject of a large intra-mural
fibroid ; suffered from sense of weight, prolonged but not
profuse menstruation, and an intra-menstrual flow, lasting
for two or three days. I injected TT\v of the ext. ergotce liq.,
with Iffx of water, twice a week for fifteen weeks, with the
following results: total cessation of the intra-menstrual
discharge of blood, and shortening of the menstrual period
by about thirty-six hours, no pain following the injection
either in the tumour or at the seat of the injection, which
was made behind the trochanter in each side alternately.

Case Y. — A married woman, never pregnant, the subject

140

DISEASES OF WOMEN.

of a large intra-uterine tumour; menstruation recurred at
intervals of fourteen days, lasted for ten days or longer; is
blanched, amcmic, and very feeble.

Ergot injected six times at intervals of two days; pain ex-
perienced at seat of the first injection, but not subsequently;
menstrual flow did not come till after an interval of twenty-
four days, and lasted but six days on its cessation; dilated
uterus and removed an intra-uterine fibrous polypus.

Case VI. — M. G. , set 48, unmarried, admitted 6tli

January, in a state of extreme anaemia, pallid and ex-sanguine,
the result of long-continued uterine haemorrhage ; she was
the subject of a huge intra-mural fibroid, very hard in texture,
and easily felt through the abdominal parietes. It reached
to within an inch of the umbilicus, and dipped deep into
the pelvis. Menstruation lasted usually for fourteen days,
and in fact she has during the past year been seldom free
from a red discharge. She was also in constant pain.

January 14 tli, IT^v of the liquid extract of ergot and
TT|_x of water was injected into the substance of the glut sc us
muscle; this was repeated on the 17th and 20th January;
she felt pain in the uterine tumour in about an hour after
the injection had been made. From this latter date the
ei’got was injected every second day, and now she stated
that severe pain commenced in the tumour immediately
after the injection, and lasted for five or six hours. But
little pain or soreness was felt at the seat of injection which
was made into the substance of the muscle on each side
alternately, the needle always penetrating to the depth of
an inch or more. A menstrual period commenced on the
22nd January, and lasted to the 28th.

7th February. — Severe pain experienced in back and
stomach, followed by vomiting, relieved by hypodermic in-
jection of morphia; injection of ergot suspended.

CHANGES IN FIBROUS TUMOURS.

141

9^ — Injection of ergot resumed.

13 th March. — Since last date the injection of ergot has
been practised regularly every second day ; great pain referred
to the rectum now experienced after defecation : catamenia
appeared on the 18th, after an interval of three weeks is
stronger, and were it not for the great pain, would be de-
cidedly better. ..

To have gr. 4 iodoform in a suppository each night, "Lvn

of ergot to be injected daily, with lllvii of water.

1 8th. — Iodoform suppository has been of much use m
relieving the pain experienced in the rectum, also that felt
.in tumour; it gives as much relief as a morphia suppository,
and does not cause sickness.

3rd April, — Menstruation appeared on the 1st, lasted only

tivo daps, tumour seems smaller.

21,^ May. — Menstrual period just over, lasted four days,
now experiences incessant pain of the most wearying diame-
ter, sometimes agonizing, demanding the repeated adminis-
tration of morphia hypodermically; appetite quite gone,
confined altogether to bed from the pain.

The injection of ergot had been now carried on contin-
uously for more than four months, and upwards of sixty
injections had been given, but though the hemorrhage
had been controlled, the patient’s condition was m no way
improved, and I reluctantly abandoned the treatment. The
result was that the hemorrhage returned with such violence
as to necessitate plugging the vagina; all this time, how-
ever, she was free from the least tendency to the forma-
tion of sores or abscesses at the site of the injections,
and this, although more than sixty had been given.

The conclusions to be deduced from the foregoing cases

are these: —

1. That Wigjer’s pure ergotin is inert, and useless foi the
purpose of hypodermic injection.

142

DISEASES OF WOMEN.

2. That Bonjeau’s ergotin, hypodermically injected, exerts
a marked effect on cases of uterine fibroids, lessening the
amount of blood lost and shortening the periods, but that
its use is liable to be followed by the formation of abscesses.

3. That the extractum ergotce liquidum, B.P., is still more
efficient in checking the uterine haemorrhage occurring in
these cases, but that its use causes at the time severe pain,
and that troublesome abscesses are very likely to form at the
site of the injection, though these are much less likely to
occur if glycerine be omitted from the solution.

From what I have already said, you will gather, that I
am not an advocate for surgical interference in cases where
large uterine fibroids exist, if it can possibly be avoided.
My reasons for arriving at this conclusion are two-fold,
namely, that the vast majority of such cases go on tolerably
well for years, and that if by plugging the vagina, by the
hypodermic injection of ergot, or the use of other means
at our disposal, we can check profuse menstruation when
such exists, there is every probability of the patient’s con-
dition improving when she arrives at the climacteric period,
and when the uterine functions cease to be actively per-
formed. But on the other hand, cases are from time to time
met with, in which surgical interference is imperatively

called for. That of M. B , whose case I have just been

alluding to, is one of these. You remember, that by the hypo-
dermic injection of ergot, we succeeded in restraining the
excessive menstrual flow, but that her condition did not im-
prove; that she became more ansemic and weaker day by day,
apparently, as a result of the excessive pain from which she
suffered, pain so intense, that the administration of morphia
by the rectum or by the skin, was imperatively required,
not once but three or four times during each twenty-four
hours. Her appetite failed, she became daily more pallid,
and if possible more emaciated ; life could not under such

CHANGES IN FIBROUS TUMOURS.

143

conditions endure very long. She begged, too, that some-
thing might be done, which would afford a chance of relief
from her sufferings, and expressed herself quite indifferent
as to the result, life having become unbearable to her. But
any possible operation involved grave responsibility, as well
as serious risk. We had to deal with a tumour which ex-
tended to within an inch of the umbilicus, and dipped down
deep into the pelvis. The os, which was very small, lay far
back, and could only be reached with difficulty; the sound
penetrated to the depth of five inches, proving that the
whole uterus was implicated. The tumour itself was firm,
dense to a degree, and I was satisfied that to dilate
the os uteri, and attempt the removal of the tumour
through it, should be a futile as well as a daugeious p> o-
ceeding. I, therefore, after much consideration, resolved
to attempt its enucleation by the use of the actual cauteiy,
applied freely through a wooden speculum to the anterior
portion of the cervix, which was stretched out over the
tumour and projected so much in front of the os, that it could
be reached without much difficulty. ' I decided on adopting
this course in consequence of the satisfactory results of this
treatment obtained by Dr. Greenhalgh, of London. The
following conditions are essential for success in such cases .
— 1st. That the tumour be intra-mural. 2nd. That it ex-
tend down to, and involve the neck of, the uterus.
3rd. That it bulge out the neck, so that on introducing the
wooden speculum, the portion of the neck selected can be
easily reached by the cautery. All these conditions existed in
the case now under our consideration. Accordingly, having
placed the patient under the influence of chloroform, I intro-
duced a full-sized wooden speculum, and through it applied
the actual cautery, causing it to burrow deeply into and
through the texture of the cervix, till it penetrated into the

144

DISEASES OF WOMEN.

substance of tlie tumour. I then placed in the vagina a
pledget of lint, saturated with glycerine, and withdrew the
speculum.

On recovering from the effects of the chloroform, the
patient expressed herself as being freer from pain, and easier
than she had been for a long time previously; this con-
dition I pointed out to you, was probably due to the lessen-
ing of the extreme tension of the uterine tissue, which had
so long existed, caused by the steady growth of the tumour
within its substance.

On the separation of the slough the tumour could be felt
through the opening formed in the wall of the uterus, like
a foetal head inside a rigid os uteri. I now divided with a
knife the portion of the uterine wall intervening between the
opening made by the cautery and the canal of the uterus (
thus laying bare the surface of the tumour to a considerable
extent. The results as yet obtained are two-fold, namely,
relief from intense pain, and diminution of the amount lost
at the menstrual period, for the period just past was by no
means excessive. The condition of the patient, too, has
greatly improved. But much still remains to be accom-
plished ; day by day we must endeavour to detach the
growth, little by little, and if a portion of it protrudes
through the opening, to remove it with the ecraseur. At
present there is a great tendency in the opening to close
altogether. Though so far the results ha\c been good,
much remains to be done, and weeks, possibly months,
elapse before the process of enucleation is completed.

I have now given you an outline of the pathology and
treatment of the various forms of fibrous tumours, but theic
yet remain two interesting and important phases of their
history, to which I must allude before concluding the sub-
ject; the one, the increase and subsequent decrease in their

CHANGES IN FIBROUS TUMOURS.

145

size, which is sometimes observed; the other, their occasional
absorption, transformation, or even elimination.

All fibrous tumours, especially the sub-mucous, when they
hang into the cavity of the uterus, are liable to become
cedematous, and to this cause many of the recorded cases of
enlargement, and subsequent decrease in their size, is lefei-
able. ° But, in addition to this cause, menstruation and preg-
nancy undoubtedly influence both the condition and size of
these growths. In many cases a fibrous tumour, which
ordinarily is productive of no discomfort to the patient, be-
comes at each menstrual period the seat of pain. This is a
fact I have several times noticed. That actual inciease in
bulk should also occur at the epoch is easily understood.
The following case, illustrating this, is recorded by Dr.
Ernest Lambert of Paris:— “Age of patient, thirty-eight;
for ten years past a tumour appeared before each menstrual
epoch, disappearing in turn to re-appear again; for a year
past it ceased to disappear, and had become the scat of severe
pain.” After death, a large fibrous tumour was found grow-
ing from the anterior surface of the uterus. From the same
author I quote the two following instructive cases:— The
first is on the authority of M. Depaul, who relates that having
been summoned to a patient at a distance fiom Palis, he
found three physicians in attendance on a primipara, sup-
posed to be three months pregnant. She had suffered, for
some time past, great difficulty both in passing water and in
defecation, and for four days previous to M. Depaul seeing
her, had been unable to empty either the bladdei 01 lcctum,
even the catheter could not be passed except with great
difficulty. She suffered from the most powerful expulsive
pains, and her agony was very great. M. Depaul recognized
the existence of a large fibrous tumour, which filled the
pelvis; the patient’s state was one of great danger. With.

146

DISEASES OF WOMEN.

difficulty ho reached the os uteri, introduced a sound and
brought on premature labour. The next day a foetus, “flat-
tened like a sheet of cardboard,” was expelled; in a short
time this tumour had decreased to a third of its former
size, and at the end of four months was not larger than a
small apple; it was situated in the anterior wall of the
uterus, near the neck.

The second case was that of a woman, set. forty-four, who
had o-iven birth to several children; she was admitted into
hospital on the 21st of March, 1869. The membranes had
ruptured before her admission, and the feet of the child were
in the vagina. The child was extracted alive, and in a few
minutes the placenta was expelled. On placing the hand on
the abdomen shortly after, a tumour as large as a child’s head
was felt at the fundus of the uterus; supposing that it was a
case of twins a vaginal examination was made, but no foetus
could be felt. As the placenta had come away, and as there
was not any haemorrhage, it was not deemed right to exploie
the interior of the uterus, but the hand laid on the abdomen
easily detected the presence of a tumour as large as the head
of a foetus at the eighth month of pregnancy; below this
large tumour a smaller one could be felt, which was supposed
at first to be the elbow of the child; careful auscultation,
however, failed to detect the sounds of the foetal heart; the
diagnosis seemed very obscure. The woman declared that
there was no cause for anxiety, as she had these tumours
after each confinement, and that they always disappeared in
a short time. The next day the large tumour was unchanged,
but in place of the sharp projecting tumour, a globular
one of smaller size existed; two days later, the large one
only could be felt. She died of fever on the 12th of April,
twenty-three days after delivery. On making a post mortem
examination, two fibrous tumours were discovered, the larger

CHANGES IN FIBROUS TUMOURS.

147

the size of a hazel nut, the other still smaller. Dr. Lambert
•concludes by saying, “we saw in this case a woman, in whom
at the moment of her accouchement, there existed in the
parietes of the uterus, tumours, of which one had the volume
of the head of a foetus, at the eighth month ; these tumours
could be as clearly made out as if they had been laid bare,
for the abdominal walls were very thin and flaccid, and the
autopsy discovered but two little fibrous tumours, of which the
largest was but the size of a nut.”* It would be quite foreign
to the scope of these lectures, for me to enter on the subject
cf the influence which fibrous tumours exercise on pregnancy,
but the two cases just quoted, clearly prove, that pregnancy
stimulates them to a very dangerous degree; and this know-
ledge should certainly induce us to warn any woman, in
whom they exist, should she consult us on the subject, that
marriage ought not be thought of.

Fibrous tumours, when left to themselves, not unfrequently
undergo changes which may not only alter their character,
but also result in an actual cure. One of the most remark-
able of these changes is the development of cavities, or cysts,
in their substance. These are especially likely to form in
tumours, the texture of which is loose. According to Sir. J.
Paget, this may be due either to a local softening and lique-
faction of portion of the tumour, with effusion of fluid in the
part affected, in which case the cavities are irregular and
without distinct parietes ; or they may be true cysts, their
cavity being lined by a membrane. In either case they may
be small and numerous, or of such great magnitude as to be
mistaken for, and treated as, ovarian cysts; a very serious
mistake indeed, and one unfortunately too often made. I
shall, however, have more to say with reference to this point

Lambert* T'Jis C°ml>U,luUs de VleriM. Tar lo Dr. Ernest J.

148

DISEASES OF WOMEN.

when I come to speak of ovarian tumours, and shall there-
fore defer making any further remark on this part of the
subject for the present.

But Nature also makes an effort, and not unfrequently a
successful one, to effect a cure in these cases. Dr. M'Clintock
has pointed out five methods by which this result may be at-
tained—namely, by 1st, absorption; 2nd, calcareous trans-
formation; 3rd, detachment; 4th, sloughing or disintegra-
tion; 5th, expulsion by the uterine contractions. Examples
of absorption have been frequently recorded, and aie suffi-
ciently numerous to induce us to postpone surgical interfer-
ence if the symptoms be not urgent, and especially if the
patient be near the climacteric period. I have two such
cases at present under observation. In one, menstruation,
which for several years past has been very profuse, is now at
the age of forty-nine become much more moderate in quan-
tity;0 this patient refused to submit to any local treat-
ment. . .

Cases are met with, in which calcareous deposits have >ccn

formed in the substance of fibrous tumours, and it is possible
that the process may extend to the entire tumour. Here is
a specimen of such which I removed after death from the
body of an old woman, who died of pneumonia in the Adelaide

Hospital.

Detachment and separation is only likely to occur in cases
of the sub-mucous variety, for in the intra-mural the forma-
tion of a long pedicle is very unlikely, and according to Dr.
Matthews Duncan, never does take place, and unless t ns
happens, the spontaneous detachment is a very unlikely oc-

currence. _ . , , . ,

But on the other hand, in the case of the embedded intra-
mural’tumour, a cure sometimes results by a process o^
sloughing, which either gradually breaks up the growth, ox

EXPULSION OF FIBROIDS.

149

if that process be confined to its muscular and mucous coats,
frees the tumour, and permits its spontaneous enucleation.

Expulsion is but a variety of the curative process last
spoken of; the uterus nearly always makes an attempt to
expel any substance which is formed within its cavity, conse-
quently polypi, and fibrous tumours, are, as a matter of fact,
frequently extruded by its contractions ; but in the case of
the latter, the expulsion seems to be of but doubtful occur-
rence, unless as the final stage of the process of spontaneous
enucleation just sjioken of.

I have purposely avoided, at present, entering into the
question of the differential diagnosis of fibrous tumours, be-
cause I think I shall treat this part of the subject with
greater advantage when considering that of ovarian disease,
with which alone it is likely to be confounded, for to mistake
a fibrous tumour for pregnancy is hardly possible ; the size
and shape may, indeed, resemble that of the pregnant uterus,
but the slow increase in its size, and the occurrence of me-
norrhagia, should alone in most cases suffice to prevent error.
There is one symptom, however, often present in a fibrous
tumour, which may mislead the careless observer, and that
is the occurrence of a bruit de soufflet. It is of but little
value as a diagnostic sign, and I merely mention it to put
you on your guard, lest you should be misled by its occur-
rence to suppose pregnancy existed. You must not, how-
ever, forget that pregnancy is not incompatible with the
presence of a fibrous tumour, and a very serious complication
it is.

Is ote. Since the foregoing sheet went to press I have commenced in a series
of cases a trial (hypodermically) of the ergotin discs, prepared and sold by
Messrs. Savory and Moore. They certainly cause less pain than the Ex. Ergotas
liq., but I am not as yet in a position to say what the effect of this preparation
of ergot in restraining haemorrhage or in checking the growth of fibroids may be.

LECTURE IX.

Inflammation of the Cervix Uteri— Ulceration of— Symptoms
of — Treatment of by Local Depletion, L itric Acid, and
Styptic Colloid— Pelvic Cellulitis— Pelvic Hcematocele.

The great frequency with which inflammatory affections of
the unimpregnated uterus occur, resulting as they do in some
of the most distressing and intractable ailments to which
women are liable, renders the subject of inflammation of the
womb, to which I propose to call your attention to-day, one
of great importance.

The cavity of the uterus is divided into two parts by the
os internum ; the upper part, that of the body, is tiiangulai
in shape, and lined by a mucous membrane, which, accoul-
ing to the researches of Dr. John "W1 illiams,* becomes thick-
ened at the approach of each menstrual period, then appeal s
to undergo a process of fatty degeneration and rapid decay,
and finally is disintegrated and cast off, forming with blood
and mucus the menstrual discharge. It is of a light giey
colour, and smooth on the surface. The lower pait, com-
monly designated the cervical canal, is circular, bulging in
its centre, and contracted at each extremity. It too is lined
with mucous membrane, continuous with that of the bod} ,
but differing from it in being thinner, and in being arranged
in transverse folds, which form the arbor vitae, the interstices

* Obstetrical Journal , No. X\ II., page o24.

INFLAMMATION OF CERVIX.

151

between which conceal numerous mucous follicles and glands.
Both these portions may simultaneously be the seat of dis-
ease, or one may be attacked independently of the other.

When speaking to you on the subject of menstruation, I
pointed out the important part which the mucous membrane
lining the cavity of the uterus played in the performance
of that function; how easily the discharge which at the
catamenial epoch it pours out might be checked, and the
ill results to be anticipated from such an occurrence. But, in
addition to affections following on interrupted or suppressed
menstruation, an unhealthy condition of both the body and
cervix is likely to occur as the result of abortion, or of im-
perfect recovery after labour at the full term, when the
involution of the uterus being retarded, that organ re-
mains enlarged and congested, a condition most favour-
able to the occurrence of inflammation. Other causes, too,
not so clearly traceable, produce congestion and inflamma-
tion of the cervix, and, as frequently, of the body of the
uterus.

Inflammation of the cervix is never of a very acute charac-
ter, but the cases we meet with in practice vary greatly in
intensity. The more acute form has two well-marked stages.
In the one, active congestion of the part exists, manifested
by great vascularity of the mucous membrane covering the
vaginal portion of the organ, which becomes of a bright pink
colour, and by engorgement and tumefaction of the substance
of the cervix, which, however, feels soft and elastic to the
touch. In the other, the mucous membrane, being denuded
of its epithelial covering, presents the appearance of an
irregular, abraded surface of a deep red hue, which pours out
a profuse muco- purulent discharge, and is studded with
numerous papillae. The os uteri is patulous, and its lips
everted, while the cervical canal is blocked up by a thick,

152

DISEASES OF WOJ1EN.

tenacious discharge secreted by the cervical glands. This
in appearance, resembles the white of egg, and is always
pathognomonic of endo-cervical inflammation. If you succeed
in removing it, and get a glimpse at the membrane lining the
interior of the cervix, you will find it also to be of a bright
red colour ; we seldom see a case in the very early stage
of the disease, the symptoms rarely being sufficiently severe
to induce the patient to seek medical aid. But in general
ere long, the inflammation extends to the cervical canal, and
then, her sufferings being increased, she applies for relief.

We have at present in the house, a well-marked example
of inflammation of the neck of the womb in the first stage,
occurring in an unmarried woman. The mucous membrane
covering the cervix is smooth, nor does abrasion at any point
exist; the os uteri is patulous, and a copious, transparent,
tenacious discharge issues from the cervical canal, picking
that its lining membrane participates in the disease.

Now contrast the appearances presented in this case, with
those you saw in the patient occupying the opposite bed.
S. B., set. thirty-four, has had two children, her illness dates
from the birth of the last, two years ago. The cervix is
greatly thickened and indurated; its vaginal portion, which
is of a deep red colour, instead of being smooth and even as
in the other, is covered over with little red papilla; which
bleed on being touched, while a copious muco-purulent dis-
charge, that has to be wiped away before the parts can be
seen, exudes from its whole surface. The os uteri is 'vciy
patulous, and is plugged with a mass of tenacious, opaque
mucus, which when removed, after much trouble, discloses a
cervical canal whose lining membrane is seen to be congested,
and covered with large vascular elevations. Here you have
an example of the second stage of cervical inflammation; the
substance of the cervix is thickened as in the former case, but,

INFLAMMATION OF CERVIX.

153

in addition, induration exists and the mucous membrane is de-
nuded of its epithelium. The surface thus exposed is covered
with granular-looking elevations, which indeed have some-
times been mistaken for granulations ; they are not however
new growths at all, but merely the papilla) which abound in
this situation, hypertrophied by the existence of the surround-
ing inflammation : finally you have a profuse muco-purulent
discharge secreted from the diseased surface. The rough-
ened condition of the mucous membrane with its enlarged
and prominent papillae secreting a muco-purulent discharge,
being a secondary condition the result of the previously
existing inflammation.

The case I have just been alluding to, affords also an ex-
cellent illustration of the condition termed “ulceration” of
the cervix ; a term the accuracy of which has been warmly
disputed. Dr. Beunet defends its use, and, on the authority
of Petit, defines ulceration as “a solution of continuity from
which is secreted pus, or a puriform, sanious, or other
matter.”* But, as we usually associate the idea of ulceration
with a loss of substance of greater extent than that produced
by the mere removal of the epithelium, I am inclined to
agree with the view held by Dr. Farre, that the term ulcera-
tion should only be applied to cases in which the loss of sub-
stance extends deeper. However, if Dr. Farre’s definition be
strictly adhered to when speaking of affections of the uterus,
examples of ulceration of that organ will prove to be very
rare. I have never seen a single instance of true ul-
ceration of the cervix uteri, as defined by him, unconnected
with specific disease; indeed I do not believe that such
occurs. All this, however, is a mere dispute about a term,
and although I do not think it strictly correct, still, to

Inflammations of the Uterus, page S2.

154

DISEASES OF WOMEN.

avoid confusion, I shall continue to apply the word ulcera-
tion to the condition we are considering.*

But, cases less severe than the one of which I have been
speaking constantly occur. In some, there is mere abrasion
of the vaginal surface of the cervix, a circle of limited extent
surrounding the os uteri, appearing red and abraded, a con-
dition which terminates abruptly just inside the os; or, you
may have cases intermediate in severity, in which the
vaginal portion of the cervix being denuded of its epithelial
covering, presents an irregular surface of a deep red colour
studded with the hypertrophied papilla; I have already
spoken of, the cervical canal, however, not being implicated
in the disease. Such a surface as that which I have last
endeavoured to describe, almost invariably secretes a copious
purulent discharge, and, in addition, there is usually a cer-
tain amount of vaginitis present. You had an excellent ex-
ample of this in the case of Mrs. H., in whom the discharge
was so profuse and weakening, that it was for its cure she
sought relief.

The milder forms of ulceration of the cervix are not of
themselves of any great importance; they seldom give rise to
distressing symptoms, nor do they necessarily cause sterility,
even when as severe as in the case of Mrs H., for she became
pregnant long before the ulceration was cured ; but then tiro
mucous membrane of the vaginal portion of the cervix alone
was engaged. It is quite otherwise when that lining the
cervical canal is implicated, for in that case the os becomes
patulous, its lips are everted, and a copious, viscid discharge
is invariably poured out by the cervical glands ; this com-
pletely fills up the os, and is seen hanging from it as a rope
of thick, semi-opaque mucus. Such a discharge is an eficc-

* An admirable summary of the arguments for, and against, the theory of
ulceration, will bo found in Dr. Graily Hewitt's work On Diseases of Women.

INFLAMMATION OF CERVIX.

155

tual bar to conception, and is pathognomonic of cervical dis-
ease ; whenever you see it, you may at once pronounce that
the patient is suffering from inflammation of the mucous
membrane lining that canal. Perhaps the best name for
this condition is endo-cervicitis, by many, however, it is termed
cervical catarrh. In it, the lining membrane, being con-
gested, is of a deep red colour, subsequently hypertrophy
takes place, and the rugae become prominent, while its sur-
face is covered with numerous vascular papillae. When this
stage is reached, not only is the os patulous, but the cervical
canal is relaxed throughout its entire length, as high at least
as the os internum.

If you proceed to introduce a sound in a case such as I
am describing, you will probably find it a matter of con-
siderable difficulty. This difficulty is caused by the point of
the instrument becoming entangled first in one, and then in
another, of the folds of the hypertrophied mucous membrane,
and it is only after the lapse of some time and the exercise
of much patience, that these difficulties can be overcome and
the cavity of the uterus reached. Some drops of blood are
nearly certain to follow the withdrawal of the sound, which
should not occur when the lining membrane of the cervical
canal is in a healthy condition.

In addition to these local changes, symptoms of a general
character are invariably present ; thus, the patient is nearly
sure to complain of back-ache, and of pain and tenderness on
pressure over the ovary, especially on the left side ; pain too
is frequently complained of along the edge of the false ribs.
When this is severe, and particularly if it becomes aggra-
vated at the approach of the catamenial period, I look on it
as indicating that the disease has extended up to the os in-
ternum. Then, irritability of the bladder and often distress-
ing pruritus are frequently present ; and, after a time, men-

156

DISEASES OF WOMEN.

struation is very likely to become profuse and weakening —
indeed, not unfrequcntly it is for the cure of the menorr-
hagia that we are consulted. This was so in the case of Mrs.
B., to whom I alluded when speaking of menorrhagia, and of
several others whom from time to time we have had in
hospital.

A very instructive case was that of the young married
woman, Mrs. . Her illness commenced soon after mar-

riage ; she did not suffer much pain, but latterly had hardly
ever been free from a sanguineous discharge ; there was also
profuse lcucorrlioea present. Before coming under my ob-
servation she had taken various astringents without benefit.
The cause of the failure of this treatment was apparent, for
on making a digital examination, the cervix felt as soft as a
piece of sponge, and on looking at it through the speculum,
it presented an appearance which I can only compare to
that of a large raspberry. The slightest touch was followed
by copious bleeding. You saw that, with the view of check-
ing the haemorrhage, I brushed over the surface with the
saturated solution of pcrchloride of iron in glycerine ; this
answered that purpose effectually; subsequently, as you may
remember, I repeatedly applied the fuming nitric acid, and
the part gradually assumed a more healthy appearance. She
was discharged cured, but not till after the lapse of many
weeks. I was inclined to attribute the condition of the
cervix in this case, to excessive sexual intercourse in a young
woman of delicate constitution.

In the foregoing outline, I have endeavoured to trace the
progress of a case commencing in inflammatory congestion of
the substance of the cervix, in which the mucous membrane
covering its vaginal aspect participating in the disease, be-
comes after a time the scat of ulceration ; that lining the
cervical canal also, being implicated in the inflammatory

INFLAMMATION OF CERVIX.

157

change. This is a very common course for the affection to
follow, and an example of it is afforded in the patient to
whose case I have just drawn your attention. It is, however,
far from being the invariable one; for, without doubt, inflam-
mation in many cases first attacks the cervical mucous mem-
brane; ulceration of its vaginal surface following; the inflam-
mation, and consequent induration, slowly extending into
the substance of the cervix.

But we may have cervical catarrh, indicating the existence
of inflammation of that canal, while the mucous membrane
covering the lips of the uterus remains peifectly healthy.
When this condition exists, we generally find that the case is
one of long standing, and that it has crept on slowly and in-
sidiously, the patient dating back the commencement of her
illness many years. I shall refer to this condition again b_y
and by.

Your treatment of cases of inflammation of the cervix uteri
must be guided by the stage which the disease has reached,
and the form which it has assumed, as well as by the patient’s
state of health. We seldom see the acute form till the stage
of ulceration has been reached. It is too commonly the cus-
tom to treat all such cases on one method, namely, by apply-
ing nitrate of silver, cither solid or in solution, to the surface
of the cervix — a treatment in general altogether insufficient,
and sometimes positively injurious. Bear in mind that you
are dealing with inflammation, or, at least, congestion of the
organ, and it is rational that your first step should be to re-
lieve that congestion by local blood-letting. There are two
ways of effecting this; the one by the application of leeches,
the other, by incising or puncturing the cervix. Leeching is
a very troublesome and tedious process, as well as most un-
certain in its results; at one time you cannot get the leeches
to take at all, or at most not more than one or two, at

158

DISEASES OF WOMEN.

another, they will bite freely, and, perhaps, in spite of all
the care you can take, will fasten on the vagina, and profuse
bleeding may follow. I have seen such profuse bleeding fol-
low the application of leeches as to compel me Fig. 24.
to plug the vagina ; I therefore now, as a rule,
rely on the other method, and practice it very
much in the same way as recommended by Dr.

Hall, of Brighton, in the Lancet for the 3rd Sep-
tember, 1870.

Merely scarifying the surface of the cervix is
not sufficient, especially in a case of a very chronic
nature and accompanied by induration ; I there-
fore always puncture the vaginal portion of the
cervix, tolerably deeply, in two or three places.

The depth to which I make the point of the
knife penetrate varies from £ to \ of an inch,
according as the cervix is soft and vascular, or
firm and indurated ; for in the former case it
bleeds very freely, in the latter it is sometimes
difficult to obtain a sufficient quautity of blood.

Dr. Hall has had a knife specially made for the
purpose by Coxeter (Fig. 24), but I often use a
long, straight-backed, French bistoury, terminat-
ing in a very sharp point which, if the former is
not at hand, answers very well. One great ad-
vantage of this plan of treatment consists in the
ease and rapidity with which it can be performed.

Having exposed the cervix with an ordinary
speculum, you make two or three punctures ra-
pidly, and then allow the requisite quantity of Hall’s Knife.
blood to flow through the speculum, on withdrawing which,
the bleeding unless the part be very vascular, generally
ceases : the operation seldom causes pain, if it does, it sub-

LOCAL DEPLETION.

159

sides in a few minutes. You can practice this treatment with
equal facility in the wards of the hospital, in the extern de-
partment, in your own study, or at the houses of your patients.

You have seen how extensively I have carried out this
system of local depletion, and how often considerable relief
lias followed its use. Of course, it is not invariably success-
ful. I have found it productive of benefit even in cases of
chronic inflammation of the cervix, although the induration
then so constantly present often prevents our obtaining a
sufficient quantity of blood.

My rule, then, in nearly all cases of inflammation of the
cervix uteri, is, first to relieve the congestion by puncturing
the part. I only omit this when menorrhagia depending on
a granular condition of the cervix is present; for should such
exist, depletion is in general unnecessary and appears some-
times to be injurious. Your object, in that case, should be
to check at once the weakening discharge. This is best
effected by applying freely to the diseased surface a saturated
solution of the perchloride of iron in glycerine, which is much
less irritating than either the tincture or the liquor, and is
generally sufficient, if applied freely, to check temporarily
the bleeding, To apply it, you should always expose the
cervix with one of Fergusson’s glass speculums, and make
your applications through it. However, this proceeding is
but palliative, and as in all severe cases the membrane lin-
ins: the interior of the cervix is implicated in the disease, it
is essential to treat every portion of the unhealthy surface of
that canal. In the majority of cases the cervical canal is re-
laxed, and the os uteri so patulous that this can be effected
without difficulty. If this be not so, I introduce one or two
lengths of the compressed sea-tangle, taking care that they
pass through the os internum ; on withdrawing these my
usual treatment has been to apply the strong nitric acid,

1G0

DISEASES OF WOMEN.

freely, to the whole interior of the cervical canal, in the
manner recommended in a previous lecture. This was the
course adopted in the case of the woman S. B., of whom we
have been speaking. I confined her to bed for three or foul-
days subsequently, and then treated the still ulcerated sur-
face by the application of a solution of tannic acid in gly-
cerine of the strength of ten grains to the ounce. I strongly
recommend the use of this application in cases of ulceration
and inflammation of the cervix after local depletion has been
practised ; it is .especially useful if vaginitis be present. Sa-
turate a pledget of cotton in the glycerine, pouring about
half a drachm of it into the palm of the hand, and soaking it
up with the cotton. Repeat this process several times till
the cotton is thoroughly saturated, and then, attaching a
piece of string to facilitate its removal, introduce it up to the
os uteri through the specidum and leave it there for twenty-
four hours; the patient can withdraw it herself by means of
the string. This treatment is often productive of great
benefit ; the tannin acts as an astringent, while the glycerine
produces a copious watery discharge. The result of this
combined action is, that the surface of the ceivix, on the
withdrawal of the cotton, looks paler and altogethei much
cleaner and healthier. If much irritation exist in the
vagina, omit the tannin and use the plain glycerine, as it le-
lieves the vaginal congestion more effectually than when it
contains an astringent. It was from Dr. Marion Sims excel-
lent work on Uterine Surgery that I first learnt the great
value of glycerine in the treatment of uterine disease, and I
daily appreciate it more. Remember, however, that glycei ine
must be very freely used; I commonly employ from half an
ounce to an ounce for a single application. The quantity
which even a small pledget of cotton will absorb is surpiis-
ingly large.

USE OF GLYCERINE.

1G1

If the nitric acid be freely applied to the whole length of
the cervical canal, and the ulcerated surface be subsequently
dressed with the glycerine of tannin, you will in many
instances effect a cure in the course of a few weeks. W c had
au example of this in the patient alluded to. If the surface
be indolent, it may be necessary to apply to it occasionally,
a solution of nitrate of silver, of the strength of from thirty
to forty grains to the ounce. In cases of less severity, I
sometimes use, instead of the nitric acid, the zinc points in-
troduced into practice by Dr. Braxton Hicks; or, if the nitric
acid has failed to effect a cure, I introduce them subse-
quently ; they arc often productive of great benefit, specially
when no induration exists. They cause, however, a good deal
of pain and considerable local irritation.

But, in the case of G. P., one of the patients I am to-day
specially directing your attention to, I have adopted a differ-
ent treatment. In her you may remember there existed
great tumefaction of the cervix, and extreme vascularity and
congestion of the mucous membrane covering its vaginal
surface. With the view of relieving this condition, I punc-
tured the cervix on three occasions and abstracted a good
deal of blood; but, although relief from paiu always followed
this proceeding, very little improvement took place in the
condition of the part. I therefore, a fortnight ago, decided
on dilating the canal of the cervix, and accordingly intro-
duced into the uterus two pieces of sea-tangle. On removing
them I applied, instead of the nitric acid, a solution lately
introduced in imitation of Dr. B. W. Richardson’s styptic
colloid, made by dissolving ten grains of benzoic acid and
fifteen grains of tannic acid in four drachms of collodion;
to which, should be added, in the treatment of uterine
disease, twenty-five grains of carbolic acid. This is both a
mild caustic and a powerful astringent, forming a coating,

1G2

DISEASES OF WOMEN.

too, over the congested and ulcerated surface, upon which, I
think, it exerts a beneficial influence by its contractile power.
The preparation is much more suitable for the treatment of
cases in which the cervix is soft and spongy, than of those in
which induration exists. In the present instance it has
proved very successful. I am not aware of the styptic colloid
having been used in Great Britain in the treatment of ul-
cerations of the cervix, but a case is recorded in the Obstetri-
cal Transactions, Yol. XI., in which it was used by Dr. Wynne,
of Guatemala, with much success.

From time to time you will meet with cases in which the
various modes of treatment I have recommended, including
the repeated application of the fuming nitric acid, will fail
to effect a cure ; this is likely to occur when the entire sub-
stance of the cervix is implicated ; when both the mucous
membrane lining its canal and that covering its vaginal
aspect, being in an unhealthy condition, are studded with
vascular papillae, and, at the same time, the cervix itself,
greatly engorged, and frequently, in my opinion, also cede-
matous. Menorrhagia was present in all the cases of this
form of uterine disease which have come under my observa-
tion ; all of them, too, were of considerable standing.

Take as an example the case of Mrs. , who has only

been recently discharged from hospital; her illness commenced
three and a-half years ago, and appears to have had its origin
in a well marked attack of inflammation; for she suffeied at
the time from acute pain over the left ovary, which only
yielded to the application of leeches and other antiphlogistic
treatment. Latterly, she experienced much pain before each
menstrual period, while the flow became very profuse
and lasted for seven or eight days. The uterus proved on
examination to be considerably enlarged, and was also ante-
fleeted; the cervix was elongated, tumefied and engorged; its

STYPTIC COLLOID.

1G3

vaginal surface was covered with large, highly vascular
granulations, from which the haemorrhage evidently pro-
ceeded; a similar condition existed in the cervical canal. I
therefore dilated it, and applied the strong nitric acid, freely,
to the diseased surface, but I was disappointed in the result.
The next menstrual period was so profuse that I had
to plug the vagina, and, though I applied the nitric acid
repeatedly, she improved very slowly indeed. I now
determined to have recourse to potassa fusa, and to de-
stroy with it, if possible, the whole of the diseased surface.
Whenever this caustic is used, it should be applied through
a glass speculum and rubbed freely against the part, till you
are satisfied that the tissues have been destroyed to a con-
siderable depth; a pledget of cotton saturated in vinegar,
should be previously inserted between the lower lip of the os
uteri and the edge of the speculum, so as to neutralize any
of the potash which may escape, and which would otherwise
irritate the vagina; that canal should also, as a further pre-
caution, be washed out with vinegar immediately after the
application. In this case I cauterized not only the exposed
surface of the cervix in the manner described, but I also
passed the stick of caustic potash to the depth of at least
half an inch into the cervical canal; this proceeding did not
cause any pain. The only local treatment I subsequently
adopted, was placing in the vagina daily, pledgets of cotton
saturated with glycerine. Of course I confined the patient
to bed for several days. The slough was thrown off in less
than a week. The surface thus exposed presented a very
healthy appearauee and healed up rapidly, so that at the
expiration of about three weeks I was able to allow the
patient to return home cured. .

In these severe cases, the t ital destruction of the diseased
surface by caustic potash is by far the most effectual means

164

DISEASES OF W03IEN.

at our disposal; and if care be taken to limit the application
to the cervix, and if the vagina be washed out freely imme-
diately afterwards with vinegar, no injury to that canal nor
any unpleasant consequences need be feared.

The milder cases of ulceration of the cervix will generally
yield to the use of nitrate of silver. Tincture of iodine some-
times seems to agree, but I do not rely on it. I have how-
ever noticed that its use seems sometimes to allay the back-
ache from which the subjects of uterine diseases suffer so
much. I also use a saturated solution of carbolic acid in
spirit, and in mild cases it answers very well.

In concluding my remarks on the treatment of the more
acute forms of cervical inflammation, especially when, as
nearly always is the case, the disease implicates the mem-
brane lining its canal, I must repeat that you have to deal
with a most troublesome, and often an intractable, affection,
and one which can only be cured by active and energetic
measures.

I stated just now, that I had seen that peculiar form of
abdominal inflammation known as pelvic cellulitis occur in
a patient suffering from inflammation of the cervix uteri.
In one case it evidently followed on the application of the
tincture of the pcrchloride of iron, which had been used with
the view of checking severe menorrhagia. It may, however,
be caused by the application of any caustic, or by exposure
to cold ; but in many instances the exciting cause cannot be
clearly traced. As we have at present a case of this affec-
tion in the house, and as it sometimes occurs in connection
with chronic disease of the uterus, I shall take the oppor-
tunity of calling your attention to the subject. Ibis patient
was admitted in a very amende condition, having lost a great
quantity of blood. She stated that she had aborted three
weeks previously, and on examining her, it was evident that

PELVIC CELLULITIS.

165

the hiemorrhage was kept up by the retention of a portion
of the placenta. I plugged the vagina, and directed her to
have thirty drops of the liquor ergot* and three of the solu-
tion of strychnia every third hour. This produced sharp
uterine action, and on withdrawing the plug, after the lapse
of twelve hours, the placenta was found in the vagina, and
the hemorrhage immediately ceased. Three days subse-
quently she had a rigor, and complained of sharp pain in
the region of the uterus ; pressure over the abdomen, how-
ever, caused but comparative little distress. Vomiting
soon after set in, and for the next forty-eight hours was in-
cessant; indeed this distressing symptom did not entirely
cease for five days. The pulse was very quick, as it always
is in these cases. On making a vaginal examination imme-
diately after the rigor had occurred, nothing could be de-
tected, but the vagina felt hot, and she complained of the
pressure of the finger causing pain. On repeating the ex-
amination, after the lapse of twenty-four hours, the uterus
was found to be immovable, being fixed by a firm, hard
swelling, which extended all round it. This, in the posterior
cut cle sac, assumed the form of a well-defined tumour which
pressed against the rectum, and thus explained a symptom
she now complained of, namely, a constant desire to defecate ;
all her attempts, however, to do so proved useless. Now,
what has occurred here is, that inflammation, which has re-
sulted in the rapid effusion of serum, has attacked the
cellular tissue situated around the uterus and within the
folds of the peritoneum.

In this case there are three points worthy of your special
;attention; namely, the hardness of the swelling as felt
through the vagina; the pressure on the rectum which this
swelling caused; and the distressing vomiting from which
she suffered. The hardness is due to the infiltration of fluid

16G

DISEASES OF WOMEN.

into the cellular tissue surrounding the uterus. This effu-
sion may be circumscribed, so as to form a well-defined
tumour, or be general, as in the present case ; its hardness,
the rapidity of its formation, and the little pain which pres-
sure causes being its distinctive features.

The pressure which the swelling exercises on the rectum
often causes much distress, and may, by totally obstructing
the bowels, even prove fatal. Let me impress on you the
necessity in such cases of avoiding the exhibition of pur-
gatives. The obstruction is mechanical, .and cannot be over-
come by exciting the peristaltic action of the bowels. On
the contrary, it is your duty to quiet that action by the ex-
hibition of opiates. This was the treatment adopted in the
case at present in the house. She took half a grain of opium
every third hour, while cnemata of tepid water were ad-
ministered twice daily, with the view of aiding the descent
of any ' fecal matter which might be impacted in the lower
part of the bowel. The opium, however, had no effect in
checking the distressing vomiting, I therefore tried the sub-
cutaneous injection of morphia, and with great success; the
injection of one-sixth of a grain always quieted her stomach
for two or three hours. Now this is a fact worth healing in
mind. Vomiting frequently follows the subcutaneous injec-
tion of morphia, but I have several times seen it check reflex
irritation of the stomach depending on uterine disease.
Vomiting is a frequent, I was almost going to say invariable,
accompaniment of pelvic cellulitis. This, I believe, is usually
due to the endometritis which generally co-exists. In the
case at present in hospital, the treatment adopted, in addi-
tion to the subcutaneous injection of morphia, was keeping
the abdomen constantly covered with warm linseed meal
poultices, and the internal exhibition of opium and of
hydrocyanic acid. Food could not for several days be rc-

•s

PELVIC CELLULITIS.

107

tained on the stomach. She had milk and lime water, and
milk and soda water in small quantities, frequently, and also
beef-tea; the latter was also administered per rectum. She
is now slowly recovering; the case will terminate by resolu-
tion.

The tendency of pelvic cellulitis is to recovery; it is always
a tedious disease, but by carefully sustaining the patient’s
strength with unstimulating nourishment, and by the avoid-
ance of lowering treatment, such as the exhibition of mer-
cury, purgatives, &c., the patient generally recovers. In
some cases resolution takes place, the swelling being
slowly absorbed, but sometimes it terminates in the forma-
tion of an abscess which may discharge into the rectum,
into the bladder or vagina, or open externally. The chief
danger consists in the risk, which always exists, of the inflam-
mation extending to the peritoneum. A little care will enable
you to discriminate between peritonitis and an attack of cellu-
litis; pressure is in the latter much better borne than in
the former, while a vaginal examination if carefully made
will in general set the question at rest, by detecting the ex-
istence of a firm, hard swelling, the uterus being fixed. The
patient whose case I have just referred to suffered from an
acute attack, but more commonly the disease creeps on in-
sidiously and its existence may for a long time escape
notice; a careful vaginal examination should, therefore, in
all cases be instituted. As an example of this latter form

the case of another patient, J. S , is instructive. She

was admitted suffering from very profuse and weakening
menorrhagia, and as the cause was not apparent the uterus
was dilated, and the intra uterine mucous membrane found to
be in a state of granular degeneration. For the cure of this
nitric acid was applied. No pain followed, and at the end of
a week the patient was convalescent. But on being allowed

1GS

DISEASES OF WOMEN.

to go about she exposed herself to cold, and an attack of
sharp fever followed, accompanied by pain referred to the
pelvis. After a time a hard swelling could be felt pos-
teriorly and laterally fixing the uterus. She was treated by
the exhibition of sedatives, rest, warm baths, &c. ; the pain
subsided, but the swelling round the uterus remained, and
after the lapse of six weeks a copious discharge of matter
per rectum proved that suppuration had taken place, and
that the abscess had burst into the bowels. Her conva-
lescence was tedious, but she was finally discharged cured.

There is one affection, of more rare occurrence, with which
pelvic cellulitis may be confounded: I allude to those cases
in which an effusion of blood takes place into the pelvic
cavity. To this affection the term of pelvic hcvmatocele is
applied, the most prominent symptom being the sudden
appearance of a tumour in the pelvis, more frequently in one
or the other iliac region, or behind the uterus. This tumour
at first is soft, but in time becomes firm and even hard ; pain
is generally complained of, and there is always a good deal
of febrile action present; often there are symptoms of col-
lapse, and generally those of nervous shock. The source
from which the blood is discharged is generally obscure,
often it is a mere exudation. Dr. Barnes is of opinion, and
I am inclined to agree with him, that this affection may re-
sult as a consequence of mechanical dysmenorrhea, and that
in such cases an ooziDg of blood from the abdominal ends of
the Fallopian tubes, and even from the surface of the con-
gested ovaries, occurs. “ Symptoms of shock announce the
out-pouring of blood into the peritoneum, or into the cellular
tissue of the broad ligaments; intense pain in the abdomen
and pelvis announce the reaction and peritonitis. In almost
all cases, a simultaneous escape of blood takes place exter-
nally” ( Obstetric Transactions, Yol. ^ II., p. 125). Ikemato-

PELVIC HJLMATOCELE.

169

celc always gives rise to grave, often to alarming symptoms,
and indeed death not nnfrequently follows its occurrence.
On some future occasiou I shall again refer to this subject,
at present I only allude to it, to warn you against con-
founding the swelling following on the escape of blood, with
that due to the occurrence of pelvic cellulitis.

LECTURE X.

Chronic Inflammation of the Cervix Uteri — Induration of
Cervix — Treatment of, by Potassa ficsa; by Local Deple-
tion— Endo-melritis — Endo-cervicitis.

In my last lecture, I gave you au outline of the history and
treatment of the more acute forms of inflammation of the
cervix terminating in congestion and thickening of the
mucous membrane lining its canal, and of the follicles with
■which that membrane is studded, while its vaginal portion
denuded of its epithelial coat is covered with numerous vas-
cular papillse; these little bodies, projecting as they do from
a rough and abraded surface, and secreting a copious muco-
purulent discharge, having been sometimes mistaken for
granulations. The term ulceration is generally applied to
the condition I have described; a term, the correctness of
which is very doubtful there being no excavation and but
little loss of substance, while the discharge is merely the
ordinary product of inflammation of a mucous membrane.

I shall now proceed to direct your attention to those still
more common cases of, what we must call, chronic inflam-
mation of the cervix. In it you have considerable thickening
and induration of the whole substance of the cervix, which
feels hard, and frequently is very sensitive to the touch. A
vaginal examination or the introduction of a speculum causes
considerable pain, while sexual intercourse may, for the same
reason, be unbearable. We frequently find this condition

CHRONIC CERVICITIS.

171

associated with flexions of the uterus; when these occur, the
fundus generally participates in the sensitive condition of
the cervix.

On exposing the cervix with a speculum, its suifacc will
frequently he found to present its normal appearance. If
any abrasion exists, it will generally be confined to a narrow
rim surrounding the os uteri, which is frequently patulous,
and, in women who have borne many children, sometimes no-
dulated and irregular, this condition being apparently due to
the slight lacerations which may have taken place during
labour. In addition, you not unfrequently have the glairy
discharge issuing from the lips of the os uteri, which is
pathognomonic of disease of the cervical canal, these cases
of chronic inflammation and induration of the cervix, u ith
little or no abrasion of the mucous membrane, are met with
constantly, especially among women of the lower class, who
leave the recumbent posture and engage in their ordinary
avocations a few days subsequent to delivery or abortion.
But it is fiir from being restricted to them ; you will meet
with numerous examples of it in the upper classes also.

I do not think that there is any affection more distressing
than chronic inflammation of the cervix. The pain in the
back, the ovarian pain, and the pain felt along the inside of
the thigh, is often even more severe than that experienced
in the acute form. The unfortunate patient never seems to
lose it even for a day, while it is sure to become aggravated
by fatigue, by exposure to cold, and by the approach of each
menstrual period. In addition, irritation of the bladder,
manifested by frequent desire to micturate, often becomes a
very troublesome and distressing symptom. This symptom,
as pointed out by Dr. Churchill, is one common, no doubt,
to other affections of the uterus, but I think I have observed
it more frequently in conjunction with chronic inflammation

172

DISEASES OF WOMEN.

of the cervix than with any other; unless indeed, it be when
anteflexion of the organ exist. In fine, though not likely in
itself to shorten life, chronic inflammation of the uterus often
renders the patient little better than a confirmed invalid,
and makes life itself a burthen.

The constant distress, and even actual pain, which patients
suffer when labouring under chronic inflammation of the cer-
vix, frequently gives rise to the suspicion of the existence of
cancer; but, the mobility of the uterus, the absence of hae-
morrhage, and of a foetid discharge, will generally enable you
to assure your patient, that, though likely to be for a long
time a sufferer, she is not labouring under malignant disease.
The induration too, resulting from chronic inflammation of
the cervix is very different from that caused by the deposit
of cancerous matter, the surface in the former being smooth,
in the latter nearly always irregular, and frequently present-
ing at one point a sharp well-defined edge, indicative of the
existence of cancerous ulceration. I have known the nodu-
lated condition of the lips of the uterus, which is sometimes
met with in women who have borne many children, and in
whom the cervix has become indurated, to be mistaken for
malignant disease; but, these irregular projections, surround-
ing as they do the os uteri, are very different in feel from
those produced by cancer. The induration which takes place
in cases of chronic inflammation of the cervix, is, according
to Dr. Bennet, due to the effusion of plastic lymph into the
tissue of the cervix.

I have already noticed that the occurrence of extensive
ulceration of the vaginal surface of the cervix is compara-
tively rare in these cases; it is not easy to explain this
circumstance. I am, however, inclined to think that the
access of the disease is so very slow, that, while lymph is
gradually deposited in the tissues of the cervix the mucous

TREATMENT OF CHRONIC CERVICITIS.

173

membrane escapes being implicated; it is different, however,
with respect to the lining membrane of the cervical canal,
which is frequently engaged to a greater or less degree; it
is not vascular and engorged as in the more acute forms, but
thickened and hypertrophied. In fact, whilst in the acute
form you have a soft, tumefied cervix, its surface denuded of
epithelium and secreting a copious muco-purulent discharge,
the cervical canal participating in the disease, and menstrua-
tion, at the same time, being nearly always profuse, you have
in the chronic form, a hard, indurated cervix, frequently
covered with an apparently healthy mucous membrane, while
a copious glairy discharge, indicative of chronic inflammation
of its lining membrane, is seen to issue from the cervical
canal — menstruation being almost invariably diminished in
quantity. These cases have long been the opprobrium of
obstetric physicians, while their extreme frequency give
them an importance which the direct effects they exercise on
the duration of life do not warrant.

The modes of treatment suggested for the cure of this
affection have been very numerous. Nitrate of silver, nitric
acid, the nitrate of mercury, and iodine have been all re-
peatedly tried with the like result, and that generally is —
failure. Equally inefficacious, as far as the local disease is
concerned, but probably more injurious to the general health,
have been the long courses of the iodide of potassium, and
of the bichloride of mercury to which such patients have
been subjected. In my opinion medicines are nearly useless
in this disease.

The failure of all ordinary means, induced the late Sir
James Simpson to try what good could be effected by the em-
ployment of potassa fusa applied directly to the indurated1
cervix, with the view, “ partly of destroying the indurated
tissues by direct decomposition, and partly to soften down the

174

DISEASES OP WOMEN.

remainder by new inflammatory action.” He found it “ far
more manageable, speedy, and certain than any other method.”

I have myself used the •pota&sa fusa with success, and I have
never seen any unpleasant consequences resulting from its
application. I do not however rely on it in cases of chronic
inflammation of the cervix; still I do not hesitate to use
it, should the means I usually employ fail to effect good
results.

I have already (page 163) explained to you the mode in
which this powerful caustic should be applied, and the pre-
cautions you should adopt to prevent its injuring the vagina,
and therefore need not repeat them here. I may, however,
add that when much induration exists, one application will
seldom be sufficient, and that it may be necessary to apply
the caustic, a second or even a third time, after the lapse of
two or three weeks.

Another valuable means, in the treatment of these cases,
consists in the application to the hypertrophied cervix of
the actual cautery ; but, instead of a metal rod heated red
hot, I now generally use ignited charcoal pencils, specially
prepared for the purpose. On another occasion* I shall give
you full direction as to the preparation and mode of using
these.

Dr. Greenhalgh, of St. Bartholomew’s Hospital, treats such
cases as these I now speak of, by the application of iodized
cotton to the cervix. The cotton is first uniformly saturated
with glycerine, a strong solution of iodine is then added and
equally diffused under pressure in a closed vessel; twenty per
cent, of iodine may thus be combined with the cotton. t 1 he
size, or weight, of the pledget of cotton to be used, is, theie-
fore, determined by the quantity of iodine required. A pledget

* See Lecture XVIT.

t The iodized cotton can be had o; Messrs. Savory and Moore, ,143 Now Bond
Street, London ; or of Graham and Co., 30 Westmoreland Street, Dublin.

LOCAL DEPLETION.

175

of the requisite size is placed in contact with the cervix, and
outside this, a roll of cotton saturated with glycerine ; strings
are attached to these to enable the patient to remove them,
when necessary. The iodized cotton doubtless exerts a
marked influence on the cervix, and many cases derive con-
siderable benefit from its use; but I find, on the other hand,
that not a few patients are unable to tolerate the strong taste
of iodine which is perceived in the mouth in a very few
minutes after its application, and remains for a long time.
In some patients too it produces considerable irritation of
the vagina, though in the great majority of cases the gly-
cerine prevents this occurring.

I find that much relief can be obtained by repeatedly punc-
turing the cervix and abstracting blood by this means locally.
Let me call your attention to some of the cases which have re-
cently been treated in this manner in our extern department.
M. W., five years married has never been pregnant. For
two years past she has suffered constantly from pain over the
left ovary, from pain along the edge of the false ribs on that
side and from back-ache, always more severely before, and
during, each menstrual period; the flow has greatly dimi-
nished in quantity, and is still progressively lessening; the
cervix was elongated, indurated, thickened, and very tender
to the touch; copious cervical catarrh was also present.
The diagnosis was obviously, chronic inflammation and in-
duration of the cervix uteri with inflammatory hypertrophy
of the mucous membrane lining the cervical canal. The cer-
vix was punctured, and the operation repeated at intei'vals of
a week; the pain steadily decreased in severity, and after the
lapse of six weeks she had obtained such relief that she con-
sidered herself to be perfectly well; no other treatment was
adopted. This patient was not cured, for, like most persons
of her class, she could not be induced to continue her attend-
ance when once the urgent symptoms were relieved.

176

DISEASES OF WOMEN.

Here is another example in which the same treatment was
adopted : — Mrs. W., set. forty, had one child nineteen years
ago, never pregnant since. Catamenia regular till seven
months ago, since then they have appeared hut twice, the
last time being three months ago. Complained of back-ache
and pain in right side, shooting down into hip ; she also
suffered from profuse leucorrhcea. Cervix in a state ex-
actly similar with what I pointed out to you as existing in the
last case. She first presented herself on the 22nd of April.
On that day I punctured the cervix which bled freely. May
2nd. — Again extracted blood by puncturing cervix; states that
she menstruated two days after last visit. May 13th. — Much
freer from pain; cervix again punctured. This was repeated
weekly, till the 20tli June— On that day, I find the following
entry in my note-book : — Is much easier ; has menstruated
again without pain. June 27th. — Quite free from pain ; cervix
still indurated but no longer tender to the touch. Here was
a woman in whom, previous to the adoption of local deple-
tion, menstruation was irregular, scanty and painful; while
she suffered constantly from distressing pain both in the
back and side. You have seen the benefit she has derived
from this treatment.

But I should only weary you by detailing the particulars
of the numerous cases I have treated in this manner. Most
of you have seen them and are capable of judging of the
effects for yourselves : I cannot, however, help alluding to that
of one woman, whose sufferings were extreme.

J. D., set. thirty, married seven years, has never been preg-
nant; for the past year has suffered from constant and severe
pain in the left groin, also over left ovary, and above the
pubes. Bladder extremely irritable, micturition painful,
catamenia very scanty and irregular, sometimes not appear-
ing at all for several months ; uterus low in pelvis and very
tender to the touch, fundu3 retroflcctcd. Sexual intercourse

VALUE OF LOCAL DEPLETION.

177

has become so painful that she cannot now pei'mit it at all.
On the occasion of her first visit, on the 12th of February, I
ordered her to have a saline purgative, and introduced a
small-sized Hodge’s pessary, hoping that the support it would
give the retroflected womb might afford some relief. In this
I was disappointed ; the organ was too tender to admit of the
instrument being worn for any length of time, and I had to
remove it after the lapse of three days. For the four follow-
ing months, she presented herself at least once a week in the
out-patients’ room, but her condition did not improve, indeed
she became worse, and she often could not straighten herself,
so great was the pain she suffered. During this period I
tried every possible form of medical treatment without effect.
On the 20th June I decided on puncturing the cervix, and
from that day she steadily improved. I repeated the opera-
tion at intervals of five or six days. After a few weeks she
was so much easier that she only attended about once a
month. On each occasion the treatment was repeated with
marked benefit. Menstruation, though scanty, appeared at
regular intervals, and she was so much better as to be able
to resume her regular occupation — that of working in a
market-garden. She presented herself the other day, after
an interval of three months. She then stated that the men-
strual flow now appears regularly, that she suffers but
little pain, and can permit sexual intercourse. The uterus
is still retroflected and will, I believe, always remain so, but
it is not painful to the touch. It is well worth your while
bearing this case in mind. Previous to practising local de-
pletion, I had, for four months, tried every other means of
treatment I could think of, without effecting the least good.
Aou all have seen the benefit resulting from that finally
adopted. This case is instructive too in another point of
view, as proving that the patient’s sufferings were due to the

ITS

DISEASES OF WOMEU.

state of chronic inflammation which was present, and not to
the retroflection.

I have hitherto spoken only of inflammation of the cervix
uteri and of the lining membrane of its canal, but the fundus
also is liable to be affected in a similar manner, and cases of
chronic metritis and of endo-metritis are very common.

I wish you to understand, that when I speak of endo-
metritis I refer to inflammation of the interior of the body of
the uterus only, that is of the part lying above the os in-
ternum. This term is used by some, I think erroneously, so
as to include inflammation of the canal of the cervix also.
Inflammation of this latter portion should be spoken of as
endo-cervicitis, a term made use of by Dr. Marion Sims, and
which I prefer as being more definite than any other.

Endo-metritis, formerly looked on as an affection of rare
occurrence, is, now that its symptoms are better known, re-
cognized as a disease of great frequency. It is met with
in°women who have never been pregnant; nay, more, I
have seen well-marked examples of it in virgins; but it
occurs most frequently as a result of imperfect involution
of the uterus, and in aggravated cases may terminate in com-
plete disorganization of the intra-uterine mucous membrane.
Such extreme cases are, however, rare.

All cases of endo-metritis necessarily fall under two heads,
namely, those in which the cervix is engaged, and those in
which that portion of the organ is not implicated, or is so in
a secondary degree. The former are, I think, the most
numerous. They are also those which frequently mislead
the unwary practitioner. He meets with a case in which
there is an enlarged and thickened cervix, with a patulous
os uteri from which exudes a copious glairy discharge, indi-
cative of endo-cervical michief. He confines his treatment
to the cervix, and perhaps cures the cervical catarrh, but is

ENDOMETRITIS.

179

disappointed at finding that his patient’s sufferings are but
little diminished ; the pain in the back, the pain felt along the
margin of the false ribs, and perhaps the dysmenorrhoea are
as acute as ever; his treatment must extend further, or it is
useless. On the other hand, if the cervix be healthy, the
existence of endo-metritis may be overlooked. I have known
numerous instances where patients were assured that no
uterine disease existed, because the cervix when exposed bv
the speculum appeared healthy.

Endo-metritis presents two well-marked stages. In the
first the body of the uterus is enlarged, the mucous mem-
brane lining its cavity being congested and swollen, while the
uterine walls are thickened, and the whole organ consequently
becomes heavy. In the second stage the walls are thinned,
the muscular structure is relaxed, and the cavity frequently
enlarged, while the mucous lining becomes soft, spongy, and
granular. In the first stage the intra-uterine discharge is
pale in colour, inodorous, and fluid. In the second it is often
rust-coloured, sanguineous, and sometimes even purulent.
This latter is specially likely to be met with when the disease
occurs in women of advanced age, in whom a copious puru-
lent discharge is frequently seen issuing from the os uteri.

The symptoms of endo-metritis, necessarily somewhat
vague, are: — Leucorrhoea, Pain, Dysmenorrhoea, or, some-
times, Irregular Menstruation, Menorrhagia, and Reflex Irri-
tation.

Uterine leucorrhoea is invariably present; but it may escape
observation, especially in the early stages, or it may be con-
founded with a vaginal discharge. Even if a speculum be
used no uterine discharge may be observed during the time
that the cervix is exposed to view. Or again, if endo-
cervicitis be present the copious glairy discharge to which
it gives origin may prevent our recognizing the other. In

180

DISEASES OF WOMEN.

the advanced stage of the disease, when the discharge becomes
rust-coloured or purulent, difficulty seldom exists in detecting
it; and I may here remark that the reddish discharge which
sometimes accompanies this affection has in the old been
mistaken for a return of menstruation. Rust-coloured, puru-
lent, or offensive discharges issuing from the interior of the
uterus may be taken as indicating extensive disorganization
of the lining membrane of its body.

Pain is invariably present. This in general is referred to
one or all of three localities; namely, to the sacrum; to the
edge of the false ribs, generally those of the left side, and
shooting up to the shoulder; and to a point immediately over
the pubes.

Dysmenorrhcca, often of a severe character, is a nearly
constant concomitant of inflammation of the intra-uterine
mucous membrane. As this is frequently observed in w omen
who have borne children, and in whom the uterine sound
passes with ease into the uterus; the supposition that this
symptom is due to any mechanical obstruction as that which
would be caused by swelling of the mucous membrane at the
os internum is in such patients negatived. In them I believe
it is due to increased sensibility of the uterus at the point of
junction of the cervix and body. This view is confirmed by
the fact that in such patients pain, identical in character
with that experienced at each menstrual period, is brought
on when the point of the instrument reaches the spot indi-
cated.

Menorrhagia is often a prominent feature, and not in-
frequently we arc consulted for it alone. Even if absent in
the early stages of the disease, it is almost certain to occur
further on, when the mucous membrane having been for a
long time engorged and inflamed, becomes covered with
numerous vascular elevations, from which the bleeding pio-

ENDO-METRITIS.

181

coeds, and -which in many cases assumes an alarming charac-
ter. An exact counterpart of these vascular elevations can
sometimes be seen on the vaginal aspect of the cervix, and
also in the rectum in granular disease of the mucous mem-
brane lining that intestine. Medicines administered by the
mouth are, therefore, here as absolutely useless, as they are
known to be in cases of haemorrhage from the rectum depend-
ing on a similar cause; and if the disease be not treated by
means of applications made directly to the diseased surface,
the hiemorrhage may continue for an indefinite time.

Symptoms due to reflex irritation are generally present
more or less markedly, in all cases of eudo-metritis, the most
pi-ominent being those of the bladder and stomach; the one
producing frequent desire to micturate, the other giving rise
to nausea and even vomiting. Occasionally, too, ovarian
and mammary sympathies are excited : specially to be noted
lest their presence should mislead and induce us to refer the
patient’s sufferings to a wrong cause.

The physical signs indicating the existence of endo-metritis
are : —

Increased length, or increased size of the cavity of the
uterus, and consequently increased bulk of the whole fundus ;
increased sensibility of the cavity of the uterus; a patulous
and often an abnormally sensitive condition of the os inter-
num; lastly, displacements anteriorly or posteriorly, of the
fundus, resulting from the increased size and weight of the
uterus.

Increased length of the cavity can be ascertained by use
of the sound; but it is necessary to discriminate between the
elongation depending on enlargement of the body and that
produced by cervical elongation; but as an ordinary digital
examination always informs us what the length of the cervix
is, moderate care will enable you to estimate coiTectly how
much, if any, of the increased length is due to the body.

182

DISEASES OF WOMEN'.

It is much more difficult to determine the size of the
cavity. If the sound can be rotated freely it may be sur-
mised that it is enlarged, but what its actual size may be
remains a matter of uncertainty.

Dr. Crecnhalgh has invented an ingenious instrument for
the purpose of measuring the capacity of the uterine cavity.
It can be expanded when introduced, and the extent of its
expansion is registered by a very simple apparatus. It is
an instrument capable in some cases of affording useful
information.

The fundus has been considerably enlarged in all cases of
endo-metritis that have come under my observation, a con-
dition in general easily detected by the by-manual method of
examination.

Abnormal sensibility of the membrane lining the cavity of
the uterus is a frequent accompaniment of this disease.
That this is so can in general be proved by pressing the
point of the sound when in the cavity against the fundus.
This in a healthy uterus causes no pain, but where endo-
metritis exist it is immediately complained of. It is a test
to be used, however, with care, for in old standing cases the
uterine walls sometimes become so thin that very little force
is needed to make the point of the sound penetrate them.

In endo-metritis the os uteri internum is always patulous,
the sound passes through it without difficulty ; but some-
times, as I have already pointed out, this, nevertheless,
causes severe pain. In those cases where endo-cervicitis exists,
the point of the sound may be entangled in a fold of the dis-
eased mucous membrane, and its further progress arrested,
but the difficulty thus produced is easily distinguished
from the resistance due to a contracted or rigid os uteri
internum.

The treatment of this troublesome and often most intract-
able affection necessarily is influenced by its duration, by the

TREATMENT OF ENDO-METRITIS.

183

severity of its symptoms, and by the prominence of some
special one of these.

If pain, nausea, and general malaise be the symptoms of
which the patient mainly complains, rest, warm hip-baths,
mild aperients, and above all the local abstraction of blood,
will do much good, and sometimes even effect a cure. But if
profuse or purulent leucorrlioea, or menorrhagia, be present,
such treatment is at best merely palliative, and treatment
applied directly to the diseased surface becomes imperatively
called for; but in all cases where much tenderness on pressure
exists, local blood-letting should first be practised.

This is a rule from which I make few exceptions. Local
blood-letting relieves the pain to a considerable degree, and
certainly favours the action of other treatment, whether that
be medicines administered by the mouth, or applications
made directly to the diseased surface.

Local depletion is a very old practice of recognized value.
It has, however, fallen into disuse, apparently because, when
carried out by means of leeches, it is troublesome, and, more-
over, is often attended with unpleasant consequences. Some-
times the leeches will not bite, at other times they will
fasten on the vagina and give rise to bleeding, alarming in
quantity and difficult to stop. Sometimes, too, notwithstand-
ing every precaution, a leech will make its way into the os
uteri. When this has occurred to myself, as it has on two
occasions, the leech returned soon, but a patient assured me
that on one occasion a leech remained in utero for twelve
hours, and gave rise to no small anxiety. For these reasons
the application of leeches to the cervix is unsatisfactory;
but I am decidedly of opinion that, as a preliminary treat-
ment, local depletion is most valuable.

I practice it, as you are aware, by puncturing the cervix.
If the cervix be soft and spongy it must be done cautiously, one

184

DISEASES OF WOMEN.

or two punctures, one-eighth of an inch in depth, will gene-
rally be followed by sufficiently free bleeding; if not, deeper
ones should be made, and if the cervix be indurated, the
point of the knife must be made to penetrate a considera-
ble depth. The quantity of blood taken can thus be regu-
lated with nicety, but a few minutes are occupied in the
operation, and no pain is caused. The bleeding generally
ceases the moment the speculum is withdrawn; if it should
not, a pledget of cotton must be placed in the vagina, and
left in situ for a few hours; but it is very rarely, indeed, that
even this is necessary. Local depletion does not produce as
beneficial results in cases of corporal endo-metritis as it does
in cases of cervical congestion; the benefit, therefore result-
ing from the practice will be in an exact ratio to the amount
of cervical disease which may exist.

Local depletion is, however, in cases of endo-metritis, but
a preliminary step ; it is nearly invariably necessary to adopt
treatment which will act directly on the diseased surface —
that is, on the mucous membrane lining the body of the
uterus.

There are three methods of making applications to the in-
terior of the uterus : one is by injecting fluids into its cavity ;
another, the introduction of a piece of solid caustic into
it by means of Simpson’s intra-uterine porte caustique ;
and a third is the passing up to the fundus, of a stilette
armed with a layer of cotton, or strip of lint, saturated with
nitric acid, carbolic acid, or some other active agent.

The first of these methods I have never tried, as it is a
practice not free from danger; and not alone that, but also
much less certain and satisfactory in its results than either
of the others.

The second I have frequently practised, in cases of imper-
fect involution of the uterus. Where no inflammation exists

ENDO-METRITIS.

185

its effects are most excellent; but it does not so far as my
experience goes, produce, by any means, such satisfactory
results in the treatment of the several forms of endo-metritis,
as nitric acid does if properly applied.

The application of strong caustics to the interior of the
uterus, of which, in my opinion, the fuming nitric acid is by
far the best, is a practice now extensively carried out, not
only in this city, but also in America.

However, some practitioners have still a great dread of ap-
plying powerful caustics to the interior of the uterus — a fear
which is totally groundless. Nitric acid seldom causes any
pain whatever, if properly applied;* in this respect its ap-
plication differs entirely from the injection of even weak solu-
tions of caustics into the uterus — -grave symptoms, and even
death, having followed the latter practice. Therefore, while I
advocate the use of nitric acid and of the solid nitrate of silver
as safe applications to the interior of the uterus, I strongly
object to the intra-uterine injection of any fluid in the treat-
ment of the class of cases under consideration.

Of numerous cases of endo-metritis, in the treatment of
which I used nitric acid, I shall give very briefly the details
of the following. The patient was a widow, and her last
child had been born twenty years ago. Of late menstruation
had become profuse, and was attended with very severe
pain. She also suffered from constant pain in the left side,
felt most intensely at a point midway between the spine
and crest of the ilium. This pain, at first experienced only
at each menstrual period, became, after a time, constant,
being aggx-avated in intensity during the periods, sometimes,
indeed, becoming at those times absolutely intolerable; there
was also tenderness over the right ovary. The uterus was

* For directions as to the mode of using nitric acid, see Lecture XVII.

ISO

DISEASES OF WOMEN*.

tender to the touch, enlarged, and retroflected. The intro-
duction of the sound caused much pain, and some blood fol-
lowed its withdrawal. The cervix was swollen and much
engorged. To relieve this condition I punctured it. It
hied freely, and, hoping to lessen the ovarian congestion, I
directed 25 grains of the bromide of potassium to be taken
thrice daily. This treatment was continued in for some
time; blood being extracted locally at intervals of five days.
The result was that the cervical engorgement was removed,
menstruation became somewhat less profuse, and the ovarian
pain much mitigated in severity; but, treatment having been
discontinued for a short time, the whole train of bad symp-
toms returned; and I became convinced that no permanent
relief would be obtained unless I treated the interior of the
uterus directly. I accordingly explained my views as to the
nature of her case to this lady, and to her son, himself a sur-
geon. She consented to undergo any treatment which pro-
mised relief from her sufferings. I commenced by dilating
the cervical canal so freely that I passed my finger through
the os internum and up to the fundus of the uterus. As I
had anticipated, I detected a rough granular condition of its
lining membrane; the lip of the uterus was then seized with
a vulsellum and drawn down, and a wire armed with a roll of
cotton, thoroughly saturated with the fuming nitric acid, was
passed up to the fundus and retained there for some seconds ;
this was done twice so as to secure a thorough cauterization
of the whole interior of the uterus. No pain followed. I
kept this lady in bed for some days as a precaution, but no
other treatment was adopted. The next period came on a
little before its time, and was profuse, but attended with less
pain. Since then her condition has steadily improved, the
periods now last but three or four days, and are almost
painless. This lady had been treated in various ways, without

ENDO-JIETIUTIS.

187

benefit, before she came under my care. I may here remark,
that if nitric acid be applied shortly before a menstrual period,
that period is likely to be profuse, but this by no means in-
dicates that the treatment is a failure, the subsequent ones,
as in the present instance, frequently becoming normal.

This case occurred before I commenced to use my plati-
num cannula.* I now but seldom find it necessaiy to dilate
the cervix in cases of endometritis, but apply the acid
through the cannula; a method which saves the patient
much suffering, and, if carefully carried out, is very efficacious.

To guard against misapprehension, I think it right to add
that, in advocating this method of treating endo-metritis, I
must be understood to refer only to cases in which menorr-
hagia, purulent discharges, or profuse uterine leucorrhoea
exist, or to cases in which other means have, on a full and
fair trial, failed to effect a rare.

Whenever endo-metritis exists for any considerable length
of time, the mucous membrane lining the cavity of the uterus
is thickened and liable to become covered with numerous
elevations, sometimes minute, sometimes so large as to be
distinctly felt by the finger introduced through the cervix.
The occim-ence of this condition I have already dwelt on
when speaking of menorrhagia, to which it nearly invariably
gives origin. We have recently had in our ward a well-
marked example of this, the particulars of which I have
detailed in a former lecture (Lecture Y). The patient suffered
from such irritability of the bladder, that for years past she
had been obliged, even during the night, to micturate at least
every hour. This was her most distressing symptom, but,
of even more importance was the menorrhagia, which had
gone on increasing in severity for ten years, and had rendered
her perfectly exsanguine. In this case I dilated the cervix.

See Lecture XVII.

188

DISEASES OF WOMEN.

passed my finger up to the fundus and found the lining
membrane of the cavity to be in a roughened, granular con-
dition. I cauterized the interior of the uterus freely with the
strong nitric acid, and had the satisfaction of seeing her com-
pletely relieved from the vesical irritation, and of discharging
her, after the lapse of a few weeks, perfectly cured also of
the menorrhagia from which she had so long suffered.

But, as already mentioned, you frequently have endo-
metritis associated with endo-cervicitis, and, as the latter is
the most obvious, may possibly refer all the symptoms to it,
and overlook the existence of the former. Consequently you
may be surprised to find, when you have cured the cervical
affection, that the patient’s sufferings are not alleviated. Dr.
Marion Sims points this out in his work on Uterine Surgery,
and I am able to confirm the accuracy of his observations.

Acute endo-metritis, excepting when it occurs after abor-
tion or delivery at the full term, is not common. 1\ hen it does
occur it is likely to be mistaken for peritonitis, to which how-
ever it presents a marked contrast in two respects — namely,
that the pain is nearly always paroxysmal in character, and
is generally accompanied by a sanguineous discharge.

The following case presents a good illustration of this affec-
tion:— A lady who had suffered from post-partum hsemorr-
hage, and in whom involution of the uterus had never been
perfectly accomplished, having been exposed to cold some
months subsequently to delivery, was attacked with severe
pain in the region of the uterus. There was also well-marked
tenderness on pressure over the pubes. The attack took
place just before the occurrence of a menstrual period, but
the flow, instead of being checked, appeared in increased
quantity and continued persistently. This lady resided in
a remote part of the country, and I did not see her till after
the lapse of about ten days. I found her in great agony, but

ACUTE ENDO-METRITIS.

189

ascertained that this was not incessant; she had intervals
of nearly perfect freedom from suffering, lasting sometimes
for several hours, and then the pain would return with great
violence. Pressure over the uterus wan always productive of
distress, and increased the pain, but elsewhere the abdomen
was not tender to the touch. The pulse was rapid, but not
of the character which accompanies peritonitis; there was no
vomiting, while a continuous though not copious hcemorr-
hagic discharge was present. On making a vaginal examina-
tion the uterus proved to be tender to the touch; it was
evidently enlarged, and on introducing the uterine sound it
passed without difficulty to the depth of five inches. I had no
hesitation in pronouncing the case to be one of metritis. As
already mentioned, the pain was of a well-marked paroxysmal
character; tenderness on pressure over the uterus was also
present, but, if the abdomen were not touched, she would
have long intervals of nearly perfect freedom from suffering;
then, however, it would come on and last for hours without
intermission — a characteristic of metritic inflammation, to
which Dr. West especially alludes in his valuable work on
Diseases of Women. He states that “the tenderness of
the uterus in these cases always led him to abstain from
measuring its depth by means of the sound.” In the case I
have just narrated however its introduction caused no pain.
The distance at which this lady resided from town precluded
me seeing her again till she wras able to travel, which vas
not for four weeks. On examining her on her ari h al in
Dublin, I was agreeably surprised to find that the uterus,
although not of its normal size, was much smaller than I
could have anticipated it would be, the cavity measuring
about three inches in depth.

In this case I enjoined perfect rest, applied poultices over
the abdomen and administered opiates. Leeches could not be

190

DISEASES OP WOMEN.

obtained, or I should have applied three or four. Mercury
in such a case as this would have been, in my opinion, abso-
lutely injurious.

I have hitherto spoken only of diseases of the mucous
membrane lining the cavity of the uterus; but the paren-
chyma is frequently also the seat of disease, being specially
liable to congestion, which often terminates in permanent
hypertrophy and enlargement of the whole organ. To this
condition the term chronic metritis is generally applied. I
agree, however, with Dr. T. Gaillard Thomas that “diffuse
interstitial hypertrophy” conveys a more correct idea of the
pathology of the affection I am now speaking of, consisting
as it does in an increased flow of blood to the part and subse-
quent static congestion, with increased growth both of the
connective tissue and of the muscular fibres of the uterus,
that of the former being greatly in excess.

Chronic metritis as thus defined is a very common affection.
It is met co-existent with, often apparently the result of,
endo-metritis ; the inflammation at first confined to the mu-
cous membrane gradually extending to the substance of the
uterus, the blood vessels of which become engoi'ged, while
the muscular structure is softened, swollen, and, in my
opinion, also frequently infiltrated with scrum to such an
extent as to produce well-marked oedema of the organ,
especially of the cervix. In fact, I have satisfied myself that
the great size which the uterus attains in many cases is due
mainly to the serous effusion which has taken place into
its muscular tissue. In addition to those cases in which
metritis appears to be due to an extension of disease from
the intra-uterine mucous membrane, we have it without
doubt depending on the irritation caused by the development
and growth of uterine fibroids. In two cases which occurred
in my own practice, I was called upon to treat a very intract-

CHRONIC METRITIS.

191

able form of metritis. Both patients were for a long time
under observation, and in both intra-mural fibioids weie
finally proved to exist. Both these patients were unmarried.
In other cases the affection seems to be of comparatively
passive origin, often the result of imperfect involution of the
uterus subsequent to delivery, which, favouring or actually
causing permanent fulness of the blood-vessels, is the first
step in a process which ends in the structural changes al-
ready described.

On whatever cause depending for its primary origin, me-
tritis when once developed is a very distressing affection, and
one most difficult of cure. That form which is connected with
the growth of a fibroid may be dismissed with a few words.
Small intra-mural fibroids are most difficult to detect, their
verv existence may not even be suspected, time alone un-
ravels the mystery when the tumour has attained a size
which enables it to be recognized ; but in metritis due to other
-causes, much may be done to alleviate the patient s sufier-
ings.

Where eudo-metritis exists it is obviously necessary that
every effort should be made to restore the mucous membiano
to a healthy condition; till this is done no progress will be
made towards the cure of the other affection. In these cases
intra-uterine medication must be used with great caution,
for under such conditions the application of nitric acid or
other strong caustic to the interior of the womb may be
followed by injurious results. It is here that local depletion
by leeching or puncturing the cervix is eminently beneficial,
especially so in those cases where oedema exists. Blisters
applied above the pubes or to the sacrum are also of great
use, while where induration exists, repeated applications of
the actual cautery promise the best results. Postural treat-
ment, that is enjoining absolute rest, the patient lying mainly

192

DISEASES OF WOMEN.

on the side or face, the shoulders being on an absolute level
with the pelvis, is an important element in the successful
treatment of these cases.

Vaginal douches of hot water, if properly carried out, are
capable of affording great relief, often of actually facilitating
a cure; they should bo administered* at a temperature of
about 105°, and be kept up for a considerable time twice
daily. Counter irritation, kept up by the application of a suc-
cession of small blisters above the pubes, is often productive
of marked relief, but to be of use, this treatment has to be
carried on for a considerable time, and it is often difficult
to induce patients to persevere with it. You may therefore
be obliged to substitute for it the daily application of iodine.
But in truth chronic metritis often proves a most intractable
affection ; its tendency is to terminate in hypertrophy and in-
duration of the whole, or at least of the body of the uterus.
When this stage is reached, benefit frequently follows from a
visit to Ems or Kreuznach ; but the stay at either place should,
to be of use. be a prolonged one.

See Lecture XVII.

LECTURE XI.

Displacements of the Uterus — Retroflexion— Causes, Symptoms ,
and Treatment of — Hodge’s Pessary — -Anteflexion — Pro-
lapsus Uteri — Retroversion.

The healthy, unimpregnated uterus is an organ of great mo-
bility. Its connection with the pelvic walls by means of the
broad ligaments, which are merely folds of the peritoneum,
is so very lax, that it can without difficulty be inclined either
anteriorly or postei’iorly ; they no doubt oppose a certain
amount of resistance to its lateral motions, but very little to
its movements in other directions, while the round ligaments,
which do materially aid in supporting it, frequently prove to
be incapable of offering any effectual opposition to the descent,
much less to inclinations of the womb in either an anterior
or posterior direction. In young women who have not borne
children, the muscular structure of the vagina, forming, as
it does, a firm tube into which the cervix uteri is inserted, aids
materially in supporting the womb; but in women in whom
that canal becomes relaxed from the effects of frequent par-
turition, or of disease, local or constitutional, the support
afforded by it is in a great measure wanting, and the organ
may sink directly down : the tendency to such a displacement
becomes greatly aggravated, should the womb, as is frequently
the case, be from any cause enlarged and heavy. But com-
mon as descent of the uterus is, the other displacements to
which the organ is liable are still more so. Hardly a day
passes in which we do not meet with examples among the ex-

194

DISEASES OF WOMEN.

tern patients of flexions of the womb either backwards or
forwards. I shall call your attention to these first, and after-
wards return to the consideration of prolapse.

The womb, then, may be bent on itself either in a posterior
or anterior direction, and to these flexions the terms “ retro-
flexion” and “anteflexion” arc respectively applied. Now it
is of importance that you should clearly understand what is
meant by these terms. Some writers, and among them the late

Fig. 25,

Sir J. Simpson, used the words “retroversion” and “retro-
flexion” as synonymous, but in reality they indicate two very
different affections, for retroversion signifies a turning back of
the entire uterus, and is applicable to that change of position
to which the gravid womb is liable when the fundus lies in
the sacral hollow, the os being forced up behind the pubes, a
condition very rarely seen unconnected with pregnancy;
whereas by retroflexion, on the other hand, is to be under-
stood a bending back of the fundus alone, the os remaining
very nearly in its natural position; while in cases of ante-
flexion, the fundus is in like manner bent forwards.

RETROFLEXION.

195

Ketroflexion, which is probably the most common displace-
ment to which the uterus is liable, may be met with at nearly

Fig. 26.

every period of life from puberty onwards. It is however
rare iii youth and in advanced age, the great majority of
cases occurring during that period of life in which the uter-
ine system is in the state of its greatest activity, namely,
between the ages of twenty and forty years. It is besides
an affection, the existence of which is very liable to be over-
looked; this being due rather to the fact that the symptoms
to which it gives rise have often but little apparent reference
to the uterus, than to any difficulty in detecting it when
once our supicions are aroused.

When we consider the position of the uterus in the pelvis
with the bladder, an organ capable of such immense disten-
sion, placed in its immediate front and frequently exercising
a pressure backwards, and when we remember that many

o 2

196 DISEASES OF WOMEN.

women from mere habit, or from motives of delicacy, often-
times pass many hours without emptying that viscus, we can
readily understand the frequency of this displacement as
compared with any other to which the uterus is liable. But,
though the distended bladder may thus be the agent in direct-
ing the uterus backwards, it is but a secondary cause ; the
uterus itself must be in an abnormal condition, for otherwise
it would regain its proper position whenever the bladder
became flaccid. Retroflexion is generally, in my opinion, pro-
duced gradually, and as the result of affections which increase
the bulk and weight of the uterus, and more especially of its
fundus. It is not however necessary that the increase should
be confined to the fundus, though, if that be the case, the
danger of retroflexion occurring is much increased; for if the
bulk of the entire uterus be augmented this may still take
place, because not only is there a force acting from before,
directing the fundus downwards and backwards, but also
because there is no resistance from behind to counteract that
tendency.

We, however, frequently meet with cases in which, while
retroflexion obviously exists, the uterus certainly is not en-
larged or increased in weight; but this is capable of explana-
tion if we bear in mind that, when the uterus is bent on itself
at an angle, the circulation must be seriously interfered with.
Congestion doubtless at first occurs, but subsequently, if the
case be neglected, atrophy of the organ may after a long in?
terval result. In time the original cause of the affection
may cease to exist; but the uterus docs not necessarily on
that account regain its normal position, for not only may the
fundus be bound down by adhesions formed on its peritoneal
surface, but also a process of absorption and consequent
thinning, may take place at the point of flexion, especially
on the lower or concave surface, so that even when no ad-

RETROFLEXION. 197

hesions exists, permanent restoration of the uterus to its
normal position is impossible ; this fact enables us to under-
stand the unsatisfactory results which often follow treatment
adopted for the cure of cases of old standing.

The causes producing the condition likely to result in re-
troflexion may be reduced to three classes — namely —

1st. Congestion, frequently terminating in chronic inflam-
mation of the uterus, and hypertrophy of that organ.

2nd. Subinvolution of the uterus, after labour or abortion.

3rd. Tumours of the uterus.

But in addition to those cases, in which we can trace the
flexion to the existence of one of the conditions here enumera-
ted, we occasionally meet with others, the origin of which is
so obscure, as to prevent our being able to decide as to the
mode of their occurrence.

Dr. Barnes suggests that in many cases the flexion may be
congenital, an opinion which I believe to be correct.

Congestion of the uterus is a common cause of retroflexion,
and one frequently overlooked. It is met with in two
very different classes of females — namely, those who lead a
very active life ; and again, in those of weakly constitution
and sedentary habits, such as needlewomen and teachers.
Thus young women of active habits, who from necessity or
for pleasure, walk, ride, or garden much, or who follow em-
ployments or amusements necessitating much standing, will
sometimes continue to pursue these duties or amusements
during the catamenial periods; the result is that the organ
remains congested for an undue length of time, and a con-
dition favourable to chronic inflammation is produced.

The following case illustrates this form of the disease: —

M. F., ret. twenty-five, unmarried, has always lived a very
active life, and, till within a compai’atively recent period,
excellent health. About three years ago having

198

DISEASES OF WOMEH.

been compelled to undertake the superintendence of a large
farm, she underwent great fatigue, generally spending from
eight to twelve hours each day in the open air, either on foot
or on horseback, and never relaxing her exertions even during
her menstrual periods. At first she suffered from a sense of
fulness and weight in the lower part of the abdomen, but to
these symptoms she paid no attention. At about the end
of a year she perceived, for the first time, a new train of
symptoms. She now experienced difficulty in passing water,
and was obliged to strain in doing so. After a little time
her sufferings were further increased by difficulty experienced
in defecation. The bowels were not actually constipated but
their action caused great pain, and the feces when passed
were as small as those of a little child. The catamenia ap-
peared regularly but in diminished quantities. I felt in this
case, as I always do when the patient is unmarried, great
reluctance to make a vaginal examination, but her sufferings
were so great and treatment directed to other organs had so
entirely failed to afford relief, that I deemed it absolutely
necessary to ascertain the condition of the uterus, and on
examining I discovered that organ to be much enlarged,
tender to the touch, and completely retroflected, its fundus
occupying the hollow of the sacrum and pressing against the
rectum ; this explained one of her symptoms — namely, the
difficulty experienced in defecation, the irritation of the blad-
der being evidently reflex. With the view of retaining the
uterus in its normal position I introduced a Hodge’s pessary.
The fundus was raised without difficulty, but the pessary
first used proved to bo too large, and caused so much pain
that, after the lapse of a few hours, it had to be removed.
On a subsequent day, however, I introduced a smaller one.
This answered admirably, and she experienced such relief
that she was able to return home, and has since followed her

RETROFLEXION.

199

ordinary occupations. In this caso the rctioflcctcd ntoius
was in a state of chronic inflammation, and to this condition
her greatest sufferings were due. In the following case,
however, no inflammation was present. The uterus was
simply congested, and a very different train of symptoms
manifested themselves.

A schoolmistress, set. twenty-one, had suffered for more
than a year from occasional attacks of vomiting, which for
the last three months had become incessant. She had been
treated in various ways, but without benefit, and at the time
I saw her in consultation with my colleague, Dr. Little,
under whose care she had been, rejected everything she
swallowed. She even vomited lime-water and milk, and this
though only one spoonful had been given at a time and at
regular intervals, no other food of any kind being allowed.
In like manner she had been fed on beef-tea exclusively, a
spoonful only being given at intervals of fifteen minutes.
The food thus taken would be retained for a time, till some
ounces had been swallowed, then the whole would be rejected.
Nevertheless she had not become actually emaciated, and she
only complained of debility, and of pain in the pit of the sto-
mach and in the back. The catamenia appeared at regular
intervals, but in much smaller quantities than formerly. On
examining the abdomen, tenderness on pressure was detected
over the left ovary, and to that spot four leeches were applied.
The effect was marked. The same afternoon the stomach
retained some beef-tea, that being the first food retained for
several weeks. The vomiting, howevei’, did not entirely cease
but still occui-red once or twice a day, nearly always in the
morning. Being now satisfied that this symptom depended
on some reflex irritation, we decided on making a vaginal
examination, and I was somewhat surprised to find the uterus
completely rctroflected. The fundus was enlarged and oc-

200

DISEASES OF WOMEN.

cupied the hollow of the sacrum. It was easily raised to its
normal position, and to retain it there I introduced a Hodge’s
pessary of small size. This was, from the very first, borne
without inconvenience, and from the time it was introduced
the vomiting entirely ceased. The catamenia subsequently
appeared in much larger quantities. I removed the pessary
after it had been worn for three months. Since then there
has been no return of her distressing symptoms, and I under-
stand that she is now married.

Both these patients were unmarried women, in both con-
gestion of the uterus occurred, which in one had reached, in
the other was slowly assuming, the form of chronic inflam-
mation; when this happens the patient’s sufferings are always
greatly aggravated. She will tell you that, in addition to
pain in the back, she suffers from severe lancinating pains
over the pubes, in the groin, and shooting down along the
course of the crural nerve. Change of posture, or any motion,
aggravates this pain, which sometimes becomes so severe as
to render walking a matter of great diflicultv.

Dr. Graily Hewitt has recently described this condition,
and applied to it the term of “ uterine lameness.” Often too
in these cases the bladder sympathises, and a constant desire
to micturate wears out the patient; touching the fundus of
the uterus causes pain sometimes of a very severe character.
Sexual intercourse therefore becomes so painful and distress-
ing as to be actually impossible. It is this form of the affec-
tion which most imperatively calls for our interference, for it
gives rise to great distress and often lays the seeds of unhap-
piness in married life.

The following case exemplifies the distress which exists
in cases of retroflexion when aggravated by the occurrence of
chronic inflammation of the uterus. S. B., mt. twenty-eight,
had been married for eight years. Not long after marriage,

RETROFLEXION.

201

•when in the fourth month of pregnancy, she fell clown stairs
and was much hurt. As the result of this accident she
aborted. For a year following she continued in a miserable
state, the pain in her hack and in the region of the uterus
being so severe that she was seldom able to leave liei bed.
The catamenia were scanty and irregular. She was at length
induced to go to Edinburgh, and placed herself undei the
care of the late Sir J. Simpson. He incised the cervix uteii,
and introduced a stem pessary. Severe inflammation fol-
lowed and the instrument had to be removed. From this
attack she recovered, and returned home feeling somewhat
better, but soon relapsed into a condition even worse than
before. She now experienced a distressing feeling of weight
in the neighbourhood of the rectum; this was greatly in-
creased at each menstrual period, which, however, recurred
regularly, the discharge being very scanty and its appearance
always ushered in by severe pain. At length she became a
confirmed invalid. Walking caused such suffering that she
dared not attempt even to cross the room.

On examining her I found the uterus was completely re-
troflected, the fundus, which occupied the hollow of the
sacrum, being very tender to the touch. The os was gaping,
freely admitting the tip of the finger, and a copious dis-
charge of semi-purulent fluid exuded from it. I leeched the
cervix on three occasions, and, when the tenderness of fundus
was lessened, introduced one of Hodge’s pessaries, which she
wore without inconvenience. Her condition has since steadily
improved. Menstruation now lasts for two or three days, and
she is able to perform her usual household duties. She still
continues to wear the pessary. In this case as well as in the
foregoing one, menstruation though not entirely suppressed
had become very scanty. The reverse will be found to be
nearly invariably present when the flexion depends on other

causes.

202

DISEASES OF WOMEN.

^ ou doubtless remember my having pointed out the fact,
that not unfrequently after labour or abortion, the uterus
from various causes fails to regain its natural size, and re-
mains unduly enlarged ; to this condition the term “ subin-
volution” is applied. When this is the case the organ is
peculiarly liable to flexions, for not only is its fundus unduly
heavy but the muscular fibres also are relaxed, consequently
the natural rigidity of the organ is in a great degree wanting.
When retroflexion occurs as a sequence of subinvolution, it
gives rise to very grave symptoms, the most prominent of
which is menorrhagia. Indeed it is frequently for the relief
of this that we are consulted.

We have recently had in our wards a good example of this
form of the affection. The patient was admitted suffering
from menorrhagia ; she stated that three months after the
date of her last confinement, menstruation came on very
profusely and lasted for six weeks, and that at each subse-
quent period the loss had been considerable. On examina-
tion the uterus was found to be retroflected, the whole organ
being also enlarged ; but it was not tender to the touch, nor
was sexual intercourse painful, and the introduction of the
uterine sound caused no distress. You see at once how
strongly this case contrasts with the ones previously detailed.
Here is another, the particulars of which I have recorded in
my note-book. A lady gave birth after a difficult labour to
a still-born child, about five months previous to my seeing
her. Considerable haemorrhage followed delivery, and her con-
valescence had been very slow. Subsequently she suffered
from profuse menstruation, had gone to the seaside and been
treated by the administration of tonics, but without effect.
On examining her, I found the uterus completely retro-
flected and much enlarged. The case was clearly one of
subinvolution of the uterus and subsequent retroflexion.
This lady did not suffer any pain. She complained of

RETROFLEXION.

203

the debility consequent on the menorrhagia and of nothing
else.

" There is no doubt but that the presence of a tumour em-
bedded in the wall, or contained within the cavity, of the
uterus may predispose to its flexion; or again, by bulging out
one wall it may simulate a flexion, although in point of fact
the axis of the uterus remains unchanged. This was so in
the patient whose case is illustrated by the woodcut, Fig. 1 L>,
page 88. The uterus in her case appeared to be anteflected,
but in reality the anterior wall had merely yielded to the
pressure exerted by the polypus as it increased in size. In
like manner fibrous tumours, if situated on the peritoneal
surface, may possibly, by their weight, draw the fundus of
the uterus downwards. Care therefore is needed to dis-
criminate between a retro- or anteflected uterus and an
intra-mural or intra-uterine tumour bulging the wall out-
wards, or an extra-uterine fibroid projecting from its surface.
It is only by means of the uterine sound that you can clear
up this point.

From the details of the cases to which I have called your
attention, you will see that the symptoms they presented
varied much; still, as I shall presently notice, they had some
well-marked points, common at least to all the cases falling
under one of the heads into which I have divided them.

If you refer to most of the works on diseases of women,
you will find the symptoms of retroflexion of the uterus
stated to be a “ sense of weight” in the pelvis, “ pain in the
back,” or “shooting down the thighs,” &c. ; symptoms which
are common to nearly every form of uterine disease, and,
therefore, worthless as a diagnostic mark ; while, with re-
spect to the state of the menstrual function, no attempt is
made to apply to it any definite rule. Thus Sir J. Simpson, in
the first volume of his Obstetric Works, says, that he has found

204

DISEASES OF WOMEN.

the “ catamenial discharge to be the most oppositely affected,
occasionally in the way of menorrhagia, sometimes of dys-
menorrhcea.” Again, Dr. Churchill says, “Menstruation may
be profuse or painful, or both.” I cannot but think, that
this apparent contradiction in the description of symptoms,
is due mainly to the want of careful discrimination between
two classes of cases, depending on totally different conditions
of the same organ.

Doubtless there is not any one symptom on which we can
rely as indicating the existence of retroflexion of the uterus;
and I do not remember in my own practice a single case in
which, prior to making a vaginal examination, I had suffi-
cient grounds for concluding that this displacement existed,
though I often surmised, and as a subsequent examination
proved, correctly, that such was the case. Thus, in the first
of the cases which I have detailed, the most prominent symp-
toms were irritation of the bladder and difficulty in defeca-
tion; in the fourth, they were pains over the ovary and total
inability to walk ; while in the second regurgitant vomiting
alone was complained of. Another case presented an ex-
ample of uterine lameness, and in her the uterus was so ten-
der to the touch, that sexual intercourse was impossible. In
these cases, however, differing as they do in other respects,
the menstrual function was similarly affected, being in all
much diminished in quantity. In two other cases, on the
contrary, menorrhagia was the sole symptom which attracted
the patient’s attention. And, again, in a case recently under
observation, although menstruation was profuse and weaken-
ing, the prominent symptom was paroxysms of intense pain.
But though the result produced — namely, retroflexion — was
in all these cases the same, the causes giving rise to that re-
sult were different. Thus, in those in which menstruation
Avas diminished, the retroflexion Avas the result of congestion,

TREATMENT OF RETROFLEXION.

205

terminating in chronic inflammation and slowly-produced
hypertrophy. In the others, where menorrhagia existed, it
followed on subinvolution, the catamenial discharge being
diminished or increased according as the flexion depended on
one or other of the causes named.

I have already noticed the occurrence of vomiting as
having been the prominent symptom in one case. This of
course was due to reflex irritation ; but the stomach is not
the only organ liable to sympathise with the uterus when it
is retroflected ; the mamma; may also be affected. Thus, I
recently was consulted by a married lady, mainly for the pur-
pose of deciding whether she was pregnant or not. She
stated that four years previously she had given birth to a
living child, and that subsequently she had been several
times pregnant, but on each occasion had miscarried at the
end of the third month. She supposed that she was now again
pregnant, because she suffered from incessant nausea, while
at the same time her breasts had become enlarged, painful,
and distended with milk; but still she was in doubt, because
the catamenia appeared not only regularly, but in increased
quantity. I speedily satisfied myself that she was not preg-
nant. The uterus was retroflected. It was manifestly a case
of subinvolution terminating in retroflexion. In this case a
pessary was at first badly borne, though finally one was in-
troduced, which answered admirably.

From the consideration of the foregoing cases, I think we
may fairly draw the following conclusions ; —

1st. That retroflexion of the uterus is a common affection,
and that it is met with both in married and unmarried
females.

2nd. That it is generally a secondary, not a primary affec-
tion.

3rd. That when it is due to congestion, or chronic inflam-

206

DISEASES OF WOJIEN\

mation of the uterus, terminating in hypertrophy, the cata-
menia are diminished in quantity and frequently painful.

4th. But, that when retroflexion is the result of subinvo-
lution of the uterus following labour or abortion, the cata-
menial discharge is increased in quantity, sometimes even to
an alarming degree.

5tli. That in addition to the symptoms common to all
forms of uterine disease — namely, pain in the back, sense of
weight, &c. — we not unfrequently have, where the uterus is
retroflected, difficulty in defecation, and in some cases reflex
irritation of the bladder, stomach and breasts, occurring now
in the order of frequency given.

It is seldom that much difficulty is experienced in recog-
nizing a retroflected uterus ; you feel a tumour in the recto-
vaginal cul ( le sac, which you can in most cases raise by mak-
ing pressure on it with the finger; and in doing so you can
generally satisfy yourself that it is the fundus of the uterus,
the cervix of which lies in its natural position ; but the use
of the sound will decide the question; for, if the uterus be
retroflected, the instrument will pass with its concavity
towards the sacrum; and when introduced you can in most
cases, by giving the handle of the instrument a half turn,
raise the retroflected fundus to its normal position, thereby
causing the tumour to disappear. It will, however, drop
back as soon as the sound is withdrawn, unless it be sup-
ported by means of a pessary.

Great difference of opinion exists among practitioners as to
the best mode of treating cases of retroflexion. Dr. Meadows
would endeavour to cure the inflammatory condition, which
is the chief causo of the patient’s sufferings, before having
recourse to mechanical treatment. I think, however, that
where a pcssaiy can be borne, the restoration of the organ
to, and the supporting of it in, its proper position, will mate-

hodge’s pessaries.

207

rially aid us in our efforts to effect a cure. The instrument
that I generally use for the purpose of supporting the retro-
flected womb, is the modification of the ring pessary, known
as Hodge’s Lever pessary ; it is oblong in shape, and has a
double curve (Fig. 27). When introduced it should lie in

Fig. 27.

Hodge’s Pessary.*

the position shown in the engraving (Fig. 28.) Those made

Fig. 28.

Hodge’s Pessary in Situ.

of vulcanised India-rubber, on which the secretions of the

* These pessaries as generally sold, and as figured in the woodcut, are not
sufficienty curved in their upper third, their value as a lever is consequently
materially lessened.

208

DISEASES OF WOMEN.

vagina take no effect, are very nice instruments. I prefer
them with transverse bars; the cervix projects through the
space behind the posterior one of these. Dr. Greenhalgh has
suggested a useful modification in the construction of these
little instruments; he has them made of copper wire cased
in India-rubber tubing, the wire however, is wanting at the
lower or wide end, the India-rubber alone extending across
that part. This is a double advantage, the yielding band of
India-rubber adapts itself to the parts, and never, by its pres-
sure, irritates the neck of the bladder, which the rigid instru-
ments sometimes do, and moreover it permits the sides of
the pessary to be approximated during its introduction, a
matter of no small importance in many cases where the
orifice of the vagina is narrow, while the elasticity of the wire
expands the pessary to its original width as soon as it is
fairly within the vagina. I have repeatedly seen these
“ spring pessaries” worn with comfort by patients who could
not tolerate the rigid ones. They have also this additional
advantage that they in no way interfere with sexual inter-
course. Instead of transverse bars Dr. Greenhalgh’s have
bands of India-rubber running across them. He recommends

Greenhalgh’s Spuing Pessaries.

that in the treatment of those troublesome cases in which
prolapse of the anterior or posterior wall of the vagina exists,

Fig 29.

RETROVERSION.

209

large-sized pessaries be worn, in which these transverse bands
extend down the entire length of the instrument, as is shown
in the annexed engraving (Fig. 29). He finds that this adds
greatly to the patient’s comfort. The only objection which
I have found to their use is, that after a time their efficacy
is apt to be lessened by the yielding and consequent stretch-
ing of these bands.

Whatever instrument you select, care must always be
taken to see that it be of suitable size and length; for if one
be introduced which is too long, it will cause much discom-
fort, and perhaps actual pain; while, if the instrument be too
small it will slip out ; you must therefore have a number of
these pessaries of various sizes by you, and remember, that
the vagina varies greatly in size in different women.

A properly fitting pessary generally affords immediate re-
lief to the patient, and may be left in situ for several weeks,
or even months. I always, however, recommend patients to
have it removed after the lapse of ten or twelve weeks, and
not to have it replaced for a few days. By adopting this
precaution, all danger of unpleasant consequences following
its use will be obviated.

Sometimes, however, Hodge’s pessaiy, even if properly
shaped, fails to raise the retroflected fundus sufficiently, and
you will from time to time meet with cases in which it be-
comes necessary to straighten the uterus by the introduction
of a stem within its cavity. The use of stem pessaries are
specially useful when dysmenorrhoca is present in connexion
with retroflexion.

Stems are very liable to slip out of the uterus. To obviate
this tendency Dr. Chambers recommends the use of a vul-
canite instrument, the stem of which is split and expands
after being introduced into the uterus. This instrument is
self-retaining, and when it can be borne often proves useful;

210

DISEASES OF WOMEN.

but an ordinary vulcanite or galvanic stem pessary can in
general be retained in situ by the subsequent introduction of
a Hodge’s pessary, or if that fail, of an ordinary box-wood
disc. Stem pessaries, of whatever kind employed, should
never be left in the uterus for a longer period than a month,
or at most six weeks, without removal.

Should, however, the uterus be so tender to the touch
that the pessary cannot be worn without causing discomfort,
you must endeavour first to relieve the tenderness by the
use of the vaginal douche, or by local depletion, practised
either by puncturing the cervix or by leeching it. Indeed
Dr. Hall considers repeated blood-letting, effected by punc-
turing the cervix, sufficient alone for the cure of flexions.
This assertion is, however, too general : it is occasionally, but
not generally sufficient. I use it as an adjunct; supporting
the cervix by means of a pessary, and at the same time en-
deavouring to bring the organ back to its normal condition
by local depletion, practised at intervals of a few days. In
fine, treatment directed to remove the cause of the flexion
should be carried out, while the uterus should, if possible, be
retained in its normal position by mechanical means.

In conclusion, I would urge on you the necessity of bear-
ing in mind that cases of retroflexion are occasionally met
with which seem to cause neither distress, nor even inconveni-
ence, to the patient, and that such cases should not on any
account be interfered with.

I must now briefly direct your attention to retroversion of
the uterus : — Retroversion of the uterus is not, at least in
its complete form, a displacement of frequent occurrence ;
doubtless partial retroversion, by which is to be understood
that condition in which the fundus inclines more or less
backwards, the whole organ lying in a sloping direction
across the pelvis, the os being still, however, its lowest

RETROVERSION.

211

point, is not very rare ; but this partial version of the womb
seldom gives rise to distressing symptoms-, and consequently,
as a rule, escapes notice. But true complete retroversion
is of infrequent occurrence. But although this displacement
is comparatively rare, still it is an aficctiou of great import-
ance, not only from the gravity of the symptoms it gives
rise to, and the serious and even fatal consequences which
may result from its occurrence, but also because of the
frequent errors of diagnosis made in relation to it.

In retroversion the uterus, as the name indicates, is turned
completely backwards, the os uteri looking upwards and for-
wards, the fundus lying in the hollow of the sacrum, and
sometimes almost on the perintcum.

It is of importance that you should bear in mind
the difference between retroversion and retroflexion of the
uterus. In the former the whole organ is, as I have ex-
plained, turned over ; in the latter it is flexed, or bent at
a point usually corresponding to the os internum. The dia-
grams, Figs 25 and 2G, will convey to you a tolerably correct
idea of these two very distinct affections, which, however,
are frequently spoken of as identical, or at most as differing
only in degree.

Retroversion, at all times a rare affection, is still more
rarely met with unconnected with pregnancy. It generally
occurs about the end of the third month of pregnancy, and
the first symptom it gives rise to, almost invariably, is re-
tention of urine. You will be asked to see a woman in
the third or fourth month of pregnancy, who will tell you
that she is unable to pass water, and on examination you
will find the bladder to be distended with urine. On empty-
ing it, you will on a further examination find that a globu-
lar body occupies the hollow of the sacrum and that the os
uteri is high up behind the pubes, possibly altogether be-

212

DISEASES OE WOMEN.

yond your reach; at the same time, a bi-manual examination
will prove the uterus to be absent from its normal position.
But possibly the patient may tell you, as in the case at pre-
sent under our observation, that she is able to pass water;
nay more, “ that it is always coming.” This is a statement
which constantly misleads inexperienced practitioners; the
dribbling of urine is under such circumstances but the
overflow of a too greatly distended bladder, and if you fail
to recognize this, and promptly to empty the bladder, your
patient’s life will be endangered, possibly lost. She may die
of peritonitis, or of uraemic poisoning, or the mucous mem-
brane of the bladder may become softened and subsequently
gangrenous, and death ensue.

The causes producing retroversion of the uterus are various.
Frequently the displacement appears to take place suddenly.
A pregnant woman makes an effort such as that requisite to
lift a heavy weight, and immediately experiences some pelvic
distress. By-and-by she finds that micturition is impossible,
and on examination retroversion is found to exist. The con-
clusion is that the displacement took place on the moment.
I doubt if this explanation is ever perfectly correct. Most
probably the uterus had been, ever since, probably before
the occurrence of pregnancy, lying in an abnormal position

namely, more or less across the pelvis, and that the sudden

muscular effort, the bladder being at the time distended,
merely completed the displacement which had previously
been in gradual progress. The subsequent retention of
urine is the result of two causes — one, that the posteiior
wall of the bladder is drawn down by the uterus, to which
it is attached; the other, that the neck of the uterus presses
upon the urethra, and thus obstructs the flow of urine. But
in some cases the patient cannot assign any cause, for the
production of the distressing symptoms from which she

KETROVEKSI ON.

213

suffers. There may have been a gradually increasing diffi-
culty in evacuating the contents of the bladder, till finally
that cannot be effected at all, or at most, but partially, only
a very small quantity of urine being voided at a time. What
has occurred under such circumstances probably is this : the
patient, previous to her becoming pregnant, may have been
the subject of retroflexion of the uterus ; pregnancy occur-
ring, the fundus of the uterus, as it enlarges, instead of
rising, sinks gradually lower, drawing down with it the pos-
terior wall of the bladder, the flexion in time being thus
converted into a version. This, however, is, I believe, of
very rare occurrence. I have on the contrary, frequently
known patients, the subjects of retroflexion of the uterus,
to become pregnant, and have observed that as utero-gestation
advanced, the fundus gradually rose, aud finally assumed its
normal shape and position. Dr. Barnes believes that this is
effected by the gradual enlargement of the fundus upwards,
there being no obstacle to its growth in that direction, and
that thus, in time, the pelvic portion is partially “ drawn
out of its lodgment.”

Cases of retroversion of the gravid uterus usually ter-
minate in one of three ways :

1. The uterus may be raised above the promontory of
the sacrum and utero-gestation proceed normally ;

2. Abortion may occur ; or,

3. Death may ensue.

I shall here detail for you the particulars of the case of
the patient at present in hospital, as she is likely to afford
an example of the first and most favourable termination of
this displacement, and it will also, I think, impress on you
deeply, the importance of being able to recognize the affec-
tion, for this woman had been under treatment for some
time before she came under my care, without the true nature
of her case being suspected.

214

DISEASES OF WOJ1EN.

A. M., a married woman and the mother of five children,
was admitted into hospital a fortnight ago, evidently suffer-
ing great pain. She stated that she had a “ tumour” in the
abdomen, which had existed ten or twelve days, during the
whole of which period she had been in constant pain. For
some time previous to the formation of this “ tumour” she
had, she said, experienced a good deal of discomfort, or
rather distress, which was greatly increased by a constant
desire to pass water, her efforts to do so being but partially
successful, only a very small quantity of urine being voided
at a time. Latterly, however, her condition had undergone
a great change ; there was now incontinence of urine, or, to
use her own words, “ it was constantly coming from her
nevertheless, her sufferings were, if possible, more intense
than ever. On passing the hand over the abdomen, a well-
defined tumour could be felt above the pubes, pressure on
which caused great pain. A vaginal examination detected
another tumour lying in the hollow of the sacrum, and
almost resting on the perinseum. The os uteri was absent
from its normal situation, lay high up behind the pubes, and
could not be reached without the greatest difficulty. Ou
questioning her she stated that, though a married woman,
she did not think she was pregnant, but, on being pressed
on this point, admitted that she had not menstruated for at
least ten or twelve weeks. On proceeding to pass a catheter
she objected, stating that this had been done the day before,
and that she was told that there was no water in the bladder.
However, being satisfied that this statement must be in-
correct, I persisted, using for the purpose an ordinary No. 0
gum-elastic catheter, and drew off about two quarts of turbid,
highly ammoniacal urine. The diagnosis was now clear, and
a careful examination verified my previous impression that I
had to deal with a case of complete retroversion of the gravid
uterus.

RETROVERSION.

215

The thorough emptying of the bladder was followed by
much pain, and fearing that peritonitis might supervene, I
desisted for a time, after one ineffectual attempt, from any
further effort at replacing the uterus in its normal position,
and with the view of allaying the pain which this woman
suffered, administered half a grain of morphia, in the foim of
a suppository.

After the lapse of eight hours, I found her in a compaia-
tively satisfactory condition. She had slept, and the pain
had nearly altogether subsided. The bladder was now again
emptied, and the patient being placed in the ordinary ob-
stetric posture, on her left side, I proceeded to endeavoui to
raise the uterus. For this purpose I introduced two fiugcis
of the right hand into the vagina, and made steady pressure
on the fundus, directing it upwards and rather to one side.
Such of you as were present will remember the stress I laid
on the apparently trifling point of making the pressure
laterally, instead of directly upwards : by so doing the pro-
montory of the sacrum, which often opposes a serious obstacle
to the ascent of the fundus, is avoided. In the present in-
stance the effort I made, as described, was attended with
complete success ; the fundus yielding to the steady pressure,
slipped above the brim, and remained there ; the patient ex-
perienced great relief, and has since progressed favourably.
The catheter was, however, used regularly night and morn-
ing for some days subsequently, for though the patient could
pass water, she was unable to empty the bladder, and it was
very desirable that no accumulation should be permitted to
occur. This precaution — namely, that the catheter be passed
twice a day in all cases in which retention has continued for
a considerable time, should never be omitted, otherwise the
bladder may not recover its tone. The subsequent history
of this patient presents no point of interest ; pregnancy is

216

DISEASES OF 'WOMEN'.

proceeding normally, and there is no reason to suppose that
she will not go to her full time.

This fortunate termination is not, however, to be frequently
expected, in the great majority of cases in which retroversion
of the gravid uterus takes place, abortion occurs either as a
direct consequence of the accident or as a result of the
treatment necessai-y to effect reposition; therefore, be always
careful to give a guarded prognosis. Thus, not long since
I was urgently requested to visit a lady who, in the twelfth
week of pregnancy, suddenly discovered that she was unable
to pass water. I found her in great agony, having for some
hours endeavoured ineffectually to relieve herself. She
stated that she had always enjoyed the most perfect health ;
that on the morning of the day on which I saw her she had
been engaged superintending some domestic arrangements,
during the progress of which she had assisted in raising a
heavy box to a considerable height; that at the moment of
making this effort she became conscious of ‘''something
giving way inside” her; but, as at the time she did not expe-
rience any discomfort, she thought no more about it, till
after the lapse of some hours, being desirous to pass water,
she discovered that she was unable to do so. By-and-by her
sufferings from this cause became severe, and she sent for
me. I at once recognized the nature of the case, emptied
the bladder, and endeavoured to raise the uterus, which I
found to be retroverted, above the brim, but my efforts wero
ineffectual. In this case I passed the catheter morning and
evening, on each occasion of doing so, endeavouring by
pressure on the fundus to replace the uterus in its normal
position, and on the sixth attempt, that is, at the end of
three days, succeeded in doing so. This patient seemed to
go on well for a time, but after the lapse of ten days, a
sharp dash of haemorrhage occurred, and she aborted. My

RETROVERSION.

217

belief is that in this case the force necessarily exerted to
replace the fundus, and not the accident itself, vas the cause
of the abortion.

But abortion is not the result most to be dreaded — death
may possibly follow. One fatal case occurred in my own
practice. This patient was further advanced in pregnancy
than either of those just alluded to, before her sufferings in-
duced her to seek relief. It was her first pregnancy, and
she was unable in any way to account for the displacement.
The symptoms appeared to have developed themselves very
gradually, and the difficulty of micturition to have been pro-
gressive, till finally it became impossible. As well as could be
ascertained she was, when I saw her, in the sixteenth week of
pregnancy; the whole of the abdomen was very tender to the
touch, and the retroflected uterus nearly filled up the true
pelvis ; the greatest difficulty was experienced in raising the
fundus. This was mainly due to the size of the uterus ; but
I am also of opinion that the uterus was bound down by ad-
hesions. Abortion occurred within twenty-four hours after
the reposition of the fundus had been effected, and she died in
a few days. I am of opinion that this may have been a case of
congenital l’etroflexion, which, under the influence of preg-
nancy, was, as previously explained, converted into one of
retroversion. The adhesions were of recent origin ; probably
local snbacute peritonitis existed previous to the raising of
the fundus, and that this subsequently spread over the
whole abdomen and proved rapidly fatal.

In the treatment of retroversion of the gravid uterus, two
indications are plainly indicated, one being to keep the
bladder empty, the other to restore the uterus to its normal
position. The former should always be effected by means of
a long gum-elastic catheter, for an ordinary silver female
catheter will often in these cases fail to reach the bladder

218

DISEASES OF WOMEN.

so greatly is the urethra elongated and displaced. The
bladder being emptied, it is generally advisable to attempt
reposition at once, unless, as in the case first narrated, great
pain is caused by doing so, under which circumstances it is
wiser to allow some hours first to elapse, care being taken to
pass the catheter at short intervals.

In the majority of cases, especially if pregnancy has not
advanced beyond the twelfth or thirteenth week, steady pres-
sure, exerted by means of two fingers introduced into the
vagina, will be successful in raising the fundus, care being
taken to make the pressure rather to one side, so as to avoid
the promontory of the sacrum. Occasionally, however, you
will fail to effect reposition by this means. When this is so
you will sometimes succeed by introducing one of Dr Barnes’
India-rubber bags into the rectum,* distending it with
•water, while pressure is still exerted by the fingers in the
vagina. If these efforts fail in raising the fundus above the
brim, no resource remains but to bring on abortion. This,
under the circumstances, is best effected by introducing a
catheter or sound into the uterus, and, if possible, rupturing
the membranes, but sometimes, in consequence of the os
uteri having been forced up behind the pubes, the introduc-
tion of a catheter or sound is impossible, and then, as a last
resource, an effort should be made to lessen the size of the
uterus by tapping it through the rectum by means of a fine
trocar or aspirator. This has been done several times suc-
cessfully; the liquor amnii having been evacuated through
the trocar, abortion followed, the patient subsequently re-
covering ; but .in all cases of retroversion the tendency to
abortion is great, and occasionally peritonitis supervenes.
Bear in mind that, in addition to abortion, the possible
occurrence of peritonitis is to be dreaded, and death may

* This method was, I believe, fust suggested by the late Dr Ilal pin, of Cavan.

RETROVERSION.

219

ensue from this cause. Retroversion, therefore, of the gravid
uterus is always to be looked on as an accident of a ^eiy
serious nature.

But supposing you have succeeded in raising the fundus,
the patient will still, under the most favourable circum-
stances, need care for a considerable time. It is essential to
attend to the state of the bladder, and to pass the catheter
at stated intervals till satisfied that the organ has regained
its tone, and you must watch lest the fundus of the uterus
fall down again into the pelvis. To lessen the risk of this
occurring, and also with a view of counteracting the tendency
to abortion, you should for some time confine the patient
strictly to the recumbent posture. As the uterus enlarges,
the risk of a relapse lessens, and after a time becomes im-
possible, but the tendency to abortion for a long time
continues, and in a comparatively small percentage of cases
does the patient reach the full time of pregnancy.

Before concluding my remarks on this subject, I must say
a few words on the question of diagnosis. In all the cases
which have come under my observation in which an erroi iu
diagnosis had been made, no sufficient examination appeared
to have been instituted ; thus, with respect to the patient
whose case I am specially alluding to, the fact that she was
suffering from retention of urine was not recognized, although
the enormously distended bladder could be easily felt above
the pubes. This negligence is quite inexcusable. But it is
just possible that an ovarian or other tumour occupying
Douglas’ space might be mistaken for a retroverted uterus,
even though an examination had been instituted, especially
if it were large enough to press against the urethra and thus
obstruct the flow of urine ; but in such a case the symptoms
of pregnancy will probably bo wanting, and, moreover, a
careful examination will detect the uterus, which, under such

220

DISEASES OP WOMEN.

circumstances, would probably have been forced up above
the pubes, lying anterior to the tumour. Any other tumour
such as that caused by the sudden escape of blood into the
recto-vaginal cul-de-sac, may, in like manner, cause some per-
plexity. All doubts, howevex-, will be dispelled if, on empty-
ing the bladder, the uterus is found lying anterior to the
tumour. Excusable errors in diagnosis, then, in cases of
retroversion of the gravid uterus, are possible, but with ordi-
nary care such should rarely, if ever, occur.

Exit the uterus, as mentioned at the commencement of this
lectixre, may be displaced in other directions besides back-
wards ; thxxs the fundus may be thrown forward towards the
pubes. Anteflexion, as this displacement is termed, is a very
tx-oublesome affection, and less amenable to treatment than
retroflexion; unfortunately it is of frequent occurrence.

Axiteflexion may exist as a congenital malformation; more
frequently, however, it is caused by the abnormal weight of the
organ, the result of congestioxx, chx-onic metritis, or subinvo-
lution. In these cases if congestion or inflammation be pre-
sexxt, I punctxxre the cervix just as in cases of reti'oflcxion, and
this treatment alone, oftexi affords marked relief. As an
example you have the case of H. E. She is an unmaxi-ied
woman, aged 30, of fxxll habit and lexxcophlegmatic tempei'a-
ment; recently she had undex’gone much fatigue. She com-
plained of severe pain, wdiiclx she referred to a point ixxxme-
diately above the pubes, but suffered even mox-e from a most
distressing sensation, “as if” to use her owxx wox'ds, “some-
thing was going to fall oixt of her.” On examining hex', the
uterxxs, which was very low in the pelvis, proved to be com-
pletely auteverted, the os lay ixx the hollowr of the sacrum,
the fundus behind the pubes. The soxxnd penetrated to the
depth of three inches. The cervix was much engoi'ged —
evidently the enlargement and sixbscqxxcnt displacement of

ANTEFLEXIOX.

221

the uterus was the result of congestion. I punctured the
cervix, which bled freely, at intervals of a few days, adminis-
tered mild saline purgatives, and enjoined rest in the recum-
bent posture. This patient obtained speedy relief from the
distressing symptoms she experienced. Menstruation became
normal, and the uterus, without my having recourse to
any mechanical support, regained its normal position. But
then, this case was one of recent origin, and to that cause we
may attribute the patient’s rapid improvement, for when
these affections become chronic additional measures are
necessary. It is most important that the fundus should be
raised to its normal position, and retained in it. The former
is in general easily effected by means of the uterine sound;
the latter is a matter of much difficulty; when it can be tole-
rated, I prefer for this purpose a stem pessary, made of
ebony, vulcanized India-rubber or aluminium. Dr. Graily
Hewitt has invented a double curved one, for the purpose of
supporting the anteflected uterus. It sometimes proves very
useful, but as often fails to act beneficially; Dr. Greenhalgh
uses flexible India-rubber stem pessaries, which beiug soft
do not cause much irritation, and are no impediment to con-
nexion. They are to be had from Arnold and Sons, West
Smithfield, London. But, in truth, anteflexion of the uterus
often baffles our utmost efforts, and in a considerable pro-
portion of cases we are able to effect but little good.

Prolapse of the uterus is another displacement of frequent
occurrence, productive of great discomfort, and, in aggravated
cases, of actual suffering, but it is by no means so common as
is supposed. Great numbers of women, especially of the poorer
classes, who present themselves among the extern patients
state that “the womb is coming down,” but on examination
the uterus is found to be in nearly its normal position, the
sensation of dragging and bearing down, being due to a re-

222

DISEASES OF WOMEN.

laxed condition of the anterior wall of the vagina, which often
protrudes slightly beyond the vulva, and is mistaken by the
patient for the womb itself. When this proceeds to any
extent, the prolapsed part contains a portion of the posterior
■wall of the bladder, and constitutes the affection known as
cystocele.

Prolapse may be partial or complete; by the former we
understand a protrusion of the cervix to a greater 01 less
extent beyond the vulva; by the latter, the rarer foim of
complete extrusion of the whole uterus. 'When this occurs
the vagina is everted, a portion of the bladder, and sometimes
of the rectum also, being drawn down with it. In cases of
old standing, when the prolapse is complete, the mass hang-
ing outside the vulva is frequently enormous; in them the

Fig. 30.

Complete Procidentia with extensive Ulceration of the Os and
VacW (after M'Clintock).

PROLAPSE.

223

surface of the tumour, specially in the neighbourhood of the
os uteri, is covered -with extensive patches of ulceration, while
the mucous membrane of the vagina, is so altered by expo-
sure and the effects of friction as to resemble true skin. The
annexed woodcut illustrates this condition (Fig 30). The
patient from whom the drawing was made, was under the care
of my friend, Dr. M'Clintock, in the Rotunda Hospital; the
prolapse was of twenty-five years’ standing. Details of the
case will be found in Dr. M‘Clintock’s work on Diseases of
Women, p. 59.

These aggravated cases are not, liowevei’, of very frequent
occurrence; more commonly when the patient stands for
any length of time a portion of the cervix protrudes, receding
when she assumes the recumbent posture. If, liowevei-, the
case be neglected, the protrusion is sure to become gradually
larger, and may in time remain permanently outside the
vulva.

Prolapse is always a very troublesome affection, the ten-
dency of which also, is to become slowly worse; judicious
treatment however, often effects much good ; absolute rest in
the recumbent posture, especially if the legs at the foot of
the couch or bed be tilted up about a foot is always of great
use, the more so as congestion is generally present. But this
postural treatment is but palliative.

Numerous kinds of pessai'ies have been invented with the
view of supporting the uterus and retaining it in its pi-oper
position. The best for general pui’poses is Hodge’s, the
same as I recommend in cases of retroflexion. You should in
cases of prolapse choose a wide one with transverse bars -
they prevent the anterior wall of the vagina from coming
down, and as this is the part which first protrudes, it is
important to support it. Another pessaiy in general use is
the disc of boxwood, or vulcanized India-rubber; those made
of the latter are much to be preferred. Globular ones are

224

DISEASES OF WOMEN.

also employed, but I dislike them very much; they are
difficult to remove, and sometimes, as occurred with the
patient wc had here the other day, can only be extracted
with the aid of a blade of the forceps. If the prolapse be
large, or the per in scum much relaxed, or if it have been de-
stroyed by laceration occurring during labour, no matter what
pessary you use, it will be forced out by the pressure con-
stantly exerted on it. In such cases, unless you narrow the
vagina by operative means, you can do but little for your
patient.

Such an operation, originally suggested by Dr. Marshall
Hall, has been modified and improved by Dr. Marion Sims.
He removes the mucous membrane in the form of a Y from
the anterior wall of the vagina, the apex being near the neck
of the bladder, and the two arms extending up on either side
of the cervix uteri. These denuded surfaces he then brings
together by wire sutures, passed transversely, thus including
a longitudinal fold of the vagina \ this has the eficct of nai-
rowing that canal considerably. In some of his more recent
operations Dr. Sims united the base of the Y by a transverse
dissection ( Uterine Surgery, p. 311). This is the best opera-
tion that can be performed, and holds out the greatest
promise of a radical cure. But I must refer you to the woik
from which I have just quoted for further information on this
point, as it is impossible for me at present to enter fully into
the subject. If there be great deficiency of the perinreum,
or if prolapse of the rectum (Eectocele) exist, it may be
necessary subsequently to perform an operation similai in
principle, but differing in details, on the posterior walls of the
vagina. This proceeding is advocated by Mr. Baker Brown.
The first of these operations has for its object the narrowing
of the vaginal canal, the latter the restoration of the pe-
rinseum.

But neither of these operations have any direct influence

PROLAPSE.

225

on the uterus itself, which is often enlarged to a great degree.
This enlargement in many cases is confined to the vaginal
portion of the cervix, which becomes greatly elongated;
while in not a few there is little if any descent of the uterus
itself.

You saw a well-marked example of this in the woman who
presented herself among the extern patients the other day-
She is an over-worked needlewoman, and tells you she sits
sewing for fourteen or fifteen hours daily. She suffers from
partial prolapse of the uterus with great elongation of the
cervix, the vaginal portion measuring at least two inches in
length. She is unmarried. The peringeum is perfect and
the vagina narrow ; therefore, in her case, neither of the
operations just mentioned is applicable, but, on the other
hand, in her you would effect much good by amputating the
cervix. I have urged this on her several times, but she is
unwilling to submit to the operation; probably the incon-
venience and distress which she suffers will by and by com-
pel her to do so.

The operation of amputation of the cei-vix is a simple one:
the hypertrophied part can be removed without difficulty by
means of an ecraseur. Great care, however, is necessary in
preventing any portion of the wall of the vagina getting
under the wire or chain ; for if this point be not attended to,
it is possible that a fold of the peritoneum, or, as occurred in a
case recently recorded, a portion of the posterior wall of the
bladder, may be drawn in and removed, and thus give rise
to very serious and possibly fatal consequences. However,
before having recourse to any operation, you should in all
cases try palliative means. It is sometimes astonishing how
much can be done by postural treatment, by astringent in-
jections, and by the judicious use of pessaries.

One other form of displacement of the uterus requires

22G

DISEASES OF WOMEN.

mention — fortunately it is a rare one — I allude to inversion.
As a rule this displacement occurs immediately after deli-
very, and if detected then, is generally capable of being re-
duced without any great difficulty ; but, should the accident
be overlooked, and the process of involution far advanced, the
case assumes a very serious aspect. It is to such cases as
these that I now refer. The treatment of the recent form
you will learn when you come to study practical midwifeiy.

The prominent symptom present in cases of chronic inver-
sion of the uterus is haemorrhage. On proceeding to examine
the patient with the view of determining the cause on which
this symptom depends, a tumour of variable size and smooth
on the surface will be detected projecting through the os into
the vagina. This tumour may possibly be mistaken for a
polypus, but a careful examination will enable you to aui\e
at a correct diagnosis. If the case be one of inversion, the
sound, which you should invariably use in such cases, cannot
be introduced, its progress being arrested by the inverted
wall of the uterus, while were the tumour a polypus having
its origin from the inner surface of the uterus, the sound
would probably penetrate to a considerable depth. At the
same time the bi-manual method of examination will prove
the fundus to be absent from its normal position, a fact which
can, if necessary, be confirmed by the introduction of a fi nger
into the rectum, the sound or a silver catheter being at the
same time passed into the bladder, when if inversion have
occurred the absence of the fundus from its normal position
will be proved by the fact that the sound can be distinctly
felt without the intervention of any solid body.

In all cases of inversion of the uterus I am of opinion that
an attempt should be made to reduce the displacement by
means of taxis, carefully and judiciously applied ; either
directly, the hand being introduced into the vagina, or
by the steady and continuous pressure exerted by an

INVERSION.

227

India-rubber bag placed in the vagina and retained
there, when inflated, by means of a bandage ; or by first
one and then another of these methods. But very great
care must always be exercised whenever taxis is tried,
otherwise the most serious censequences may follow the
attempt. Chloroform, in all such cases, should be freely
administered.

Should taxis fail, Dr. Barnes advocates incision of either side
of the cervix. He directs you to “draw down the uterine
tumour by means of a loop of tape slung round the body, so
as to put the neck of the tumour upon the stretch; then
with a bistoury make a longitudinal incision about half an
inch long and a quarter of an inch deep, on either side into
the constricting os; then re-apply the elastic pressure. Next
day, try the taxis and re-apply the elastic pressure if neces-
sary” ( Obstetric Operations, p. 449.) Should taxis, steadily,
carefully, and repeatedly tried, fail to reduce the inversion,
no means remain at our disposal save amputation of the in-
verted fundus. This if attempted should be performed with
an ecraseur. It is an operation attended with considerable
risk, and therefore it should not be undertaken unless de-
manded by the presence of urgent symptoms.

It is astonishing how often steady, continuous pressure ex-
erted in the manner described will prove successful; but it is
not sufficient that the fundus be returned within the os uteri.
It is essentially necessary to take precautions to insure the
complete restoration of the fundus to its normal shape, other-
wise the case may be only converted from one of complete
into one of partial inversion, a change hardly likely to be for
the better. It is therefore advisable if the finger be not lono-
enough, to pass some round, smooth body into the uterus to
prove that the restoration has been perfect, the bi-manual
method of examination being besides invariably practised to
confirm this. q 2

LECTURE XII.

Enlargements of the Uterus — Frequency of — Causes of,
Considered with reference to diagnosis.

You must have noticed the extreme frequency with which I
use the uterine sound. Indeed, I may say, that I invariably
employ it in the examination of all cases presenting symp-
toms of uterine disease, unless its introduction is contra-indi-
cated by the existence of some special cause. My reason for
doing so is this, that in a very large proportion of such cases
I find the uterus enlarged and elongated. The sound
enables me to ascertain whether this is the case or not;
should it be so, it immediately becomes my duty to en-
deavour to decide as to the cause on which that abnormal
condition depends. I think, therefore, by directing jour
attention to some of the causes producing enlargements of
the uterus, I shall aid you considerably in forming a correct
diagnosis in many cases of uterine disease; for, ■while the
subject of flexions of the uterus has of late yeais been in\ esti-
gated with great cai’e and has attracted quite as much atten-
tion as it deserves, the condition I am referring to, though
intimately connected with, often indeed the cause of, these
flexions, has been comparatively little noticed.

It is not surprising that the older writers should have
overlooked this condition, for it is only of recent years that
we possess the means of investigating them, and of ascertain-
ing with any approach to accuracy, whether, in a given case,

ENLARGEMENTS OF THE WOMB.

229

the uterus was of its normal size and shape, or enlarged and
elongated. Now, however, matters are completely altered;
by means of the uterine sound we can, in the great majority
of instances, measure accurately the depth of -the cavity of
the uterus; and at the same time, the bi-manual method of
examination enables us to satisfy ourselves whether or not
the uterine walls are thickened and hypertrophied.

Enlargement of the womb is met with in a very large per-
centage of those cases in which that organ is affected. Nor
is this a matter of surprise when we remember the changes
the uterus undergoes. In the virgin state, but a couple of
inches in length and an ounce or so in weight, it becomes,
under the influence of pregnancy, developed into a large
organ capable of containing the full-grown foetus, and weigh-
ing several pounds; consequently any circumstance which
retards or prevents the return of the uterus to its normal
size after delivery, may produce, as is now well known, a con-
dition which often results in permanent enlargement, a con-
dition to which, as I have already explained, the term
“subinvolution” is applied. But, in addition to these great
changes, the result of pregnancy, the uterus every month, a3
each catamenial period comes round, increases in weight, and,
probably, somewhat in size; if, from any accident or impru-
dence the natural flow is then checked, this temporary
increase may become permanent, an accident wThich, I am
satisfied, is far from being of unfrequent occurrence. Here,
then, at the outset, are two palpable causes of enlargement
of the uterus.

W e meet, however, with cases of enlargement of the uterus
■which cannot be referred to either of these classes. Women
who have never been pregnant, and never have had any de-
rangement of, or departure from, healthy menstruation, and
women who having conceived, have subsequently enjoyed

230

DISEASES OF WOMEN.

uninterrupted good health for years during which preg-
nancy undoubtedly did not take place, nor yet any derange-
ment of menstruation occur, occasionally begin to suffer from
symptoms referable to the uterus, and, on examination, that
organ is found to be enlarged. This, in such cases,
may depend on inflammation of the substance of the uterus,
either of an acute or chronic character; on hypertrophy of
the muscular and areolar tissue of the uterus; on the pre-
sence of fibrous tumours developed in the walls of the uterus,
and also, as all are aware, on the existence of intra-uterine
tumours of any kind, whether they be polypi, fibrous or
cancerous tumours. But, it is not my intention here to
enter at all on the subject of either uterine polypi or uterine
tumours, except with reference to the question of diagnosis.
I also purposely omit all reference to the actual existence of
pregnancy, or to the retention of any of the products of
conception in the uterus, as being foreign to the subject to
which I wish especially to direct attention.

To recapitulate, we meet with enlargement of the uterus
as the result of —

1st. Subinvolution of the uterus after labour or abortion.

2nd. Congestion of the uterus from suppression or retard-
ation of menstruation.

3rd. Acute inflammation of the uterus, or possibly of its
peritoneal covering.

4th. Chronic inflammation of the uterus.

5th. Hypertrophy of the uterus.

6th. The stimulus given to the uterus by the develop-
ment in its walls of fibrous tumours.

7th. The existence of intra-uterine tumours.

1. Subinvolution of the uterus is now a well-known cause
of uterine enlargement. There is no doubt but it is most
likely to occur in those cases in which any form of inflamma-

ENLARGEMENTS OF THE WOMB.

231

tory attack, whether it be peritonitis, metritis, or cellulitis,
takes place subsequent to delivery. This fact has been
pointed out by several writers. If, then, a patient has suf-
fered from any such attack, the possible effect of it in letard-
ing the normal reduction in the size of the uterus, which
should take place within a few weeks subsequent to delivery,
must be borne in mind, and we should, in such cases, carefully
watch for any symptom indicating the presence of this con-
dition. As a nearly invariable rule, profuse menstruation is
the first and most prominent symptom indicating the exist-
ence of enlargement of the uterus depending on subinvolu-
tion j a symptom capable of being easily explained, when we
bear in mind the fact, that not only is there under such
circumstances an undue amount of blood contained in the
enlarged uterine veins, but also, that the relaxed condition
of the muscular tissue of the uterus favours the exudation of
blood. Profuse menstruation does not always occur im-
mediately; sometimes months first elapse; but ere long,
menstruation becomes profuse, and, on instituting an exami-
nation, the sound reveals the true state of the case by proving
that the uterus is abnormally elongated. The depth of the
uterine cavity in cases of sub-involution varies greatly in
such cases. It seldom exceeds three and a-half inches, but
I met with one instance in which it measured upwards of
five inches.

2. The occurrence of enlargement of the uterus from any
cause suddenly checking menstruation, I believe to be by
no means rare, but opportunities of proving this do not
frequently occur; for, if an unmarried woman complains of
fulness and pain in the head, of pain in the back, and
of a sense of weight in the pelvis, and states that menstru-
ation has been checked by exposure to cold or by some
other obvious cause, we are probably satisfied that uterine

232

DISEASES OF WOMEN.

congestion exists; but, we are not justified in making a
vaginal examination, unless that after a protracted trial,
general treatment fails to relieve her. Again, if a married
woman exhibits the same train of symptoms, the possibility
of pregnancy precludes the use of the sound. Recently,
however, I had an opportunity of verifying the fact. A
widow, the mother of thirteen children, in whom menstrua-
tion had been irregular for three years, had in June last,
after a long interval, a return of the discharge. It ceased
suddenly, and she suffered great discomfort from a distress-
ing sensation of weight and bearing down in the pelvis, and
of fulness and pain in the head. In her case the uterus was
three inches in depth, while all the symptoms rapidly sub-
sided under treatment. It may be objected that, in this
case, we were ignorant as to what might have been the con-
dition of the uterus previously; but, here was a woman in
the enjoyment of good health, suddenly attacked, after the
abrupt checking of menstruation, with distressing symptoms,
in whom the uterus was proved to be enlarged, and who was
relieved of those symptoms and of that condition by treatment.
Is it not then fair to reason that the enlargement was a tem-
porary condition, the result of uterine congestion, itself
caused by the sudden checking of menstruation 1

3. All modern writers agree that acute inflammation may
produce enlargement of the uterus, and I believe that this
may be the case, whether the patient suffers from peritonitis,
metritis, or pelvic cellulitis. Of the two latter I have no
doubt. Of enlargement of the uterus as the result of peri-
tonitis, I had no experience till very recently, but the follow-
ing case throws some light on the subject : —

Mrs. K., ict. 33, was admitted into the Adelaide Hospital
suffering from menorrhagia and great pelvic distress. Her
last child was born fourteen months previous to admission.

ENLARGEMENTS OF THE WOMB.

233

She stated that four weeks after her confinement, having
been exposed to cold, she was attacked with severe pain over
the whole abdomen. The pain, after a time, became local-
ized in the left iliac fossa, and, by degrees, nearly entirely
disappeared. At the expiration of two months from the date
of this attack menstruation came on very profusely, and
lasted for six weeks. She now obtained medical advice, and
was treated for ulceration of the os uteri; but although the
menorrhagia was in some degree checked, the pain from
which she suffered again became very severe. On admission
into hospital the uterus was found to be retroflected, and a
certain amount of granular erosion existed ; menstruation
was profuse. The uterus was enlarged to a trifling extent.
The use of a pessary and other appropriate treatment
speedily improved the condition of the womb, and she re-
turned home apparently cured. At intervals, however, she
still suffered from attacks of abdominal pain. But she again
caught cold, and was re-admitted into hospital labouring
under a well-marked attack of sub-acute peritonitis. Leeches,
fomentations, and the exhibition of opium relieved her.
During the course of this attack I twice measured the depth
of the uterus, and found that it had increased in length by
nearly an inch. She did not menstruate during this attack-
4. Chronic inflammation of the uterus being of more fre-
quent occurrence than the acute form, is a more common
cause of enlargement. Such cases are constantly coming
under observation. They are frequently found in connection
with retroflection of the uterus. In these cases menstruation
is generally diminished, unless, indeed, a granular condition
of the intra-uterine mucous membrane also exist; but this
is not the form of uterine disease in which that condition is
most likely to occur. The amount of elongation, too, in
these cases is seldom great, the depth of the uterus seldom
exceeding three inches.

234

DISEASES OF WOMEN.

5. Next I shall call your attention briefly to that condition,
which, for lack of a better name, I term hypertrophy of the
uterus. I mean to include under this head those cases in
which the whole of the uterus, or some portion of it, slowly
and imperceptibly increases in size. Sometimes the cervix
alone is implicated, that portion of the organ becoming elon-
gated and thickened, or the body alone may be affected, while
in other cases the body and cervix are equally engaged, and
become thickened, enlarged, and frequently painful, the
pain being apparently due either to hyperesthesia of the
nerves of the uterus, or to the pressure exercised on them by
the hypertrophied tissue by which they are surrounded.

In these cases menstruation, as a rule, is but little altered
in its character; sometimes it is slightly diminished in quan-
tity and not unfrequently becomes painful, but I do not
remember meeting with a case in which menorrhagia was
present.

The pathology of this form of uterine enlargement is very
obscure; the fibres composing the muscular tissue of the
uterus appear to be elongated and thickened, while there is
also hypertrophy of the areolar tissue. Both conditions may
have their origin in a low form of inflammation which at the
time escaped observation; bnt we cannot in the present state
of our knowledge, say why in a certain case the cervix
uteri elongates and enlarges till by its very size and weight
it irritates and causes distress; while, at the same time, the
body and fundus of the uterus participating in the unhealthy
condition of the cervix become heavy and elongated, and in
another case, seem to remain in their normal condition. Ex-
cessive indulgence in sexual intercourse has been set down
as a cause of enlargement and hypertrophy of the cervix,
but I doubt this much.

A case of hypertrophy of the cervix, occurring in an un-
married woman, has recently come under my observation.

HYPERTROPHIC ALLONGEMENT.

235

She is a dressmaker, let. 28, an industrious woman, sitting at
work for upwards of twelve hours a day. She complained of
weight in the pelvis and of hearing down. She also suffered
from the most obstinate constipation. Menstruation was
regular, but generally accompanied by pain. On making an
examination the os uteri was found to rest on the perinseum ;
the cervix was elongated and thickened, and the fundus
slightly enlarged. This woman would not come into hospital,
and consequently I have had no opportunity of trying the
effects of treatment, from which, in truth, I would anticipate
but little benefit.

Any person who has read MM. Bernutz and Goupil’s work
on Diseases of Women, published by the New Sydenham
Society, will at once see that the condition I am now refer-
ring to is very similar, if not analogous, to that termed by
M. Huguier, “hypertrophic allongement” of the uterus; a
condition which he divides into two classes— namely, sub-
vaginal and supra- vaginal, a division the actual value of which
I do not highly appreciate. I am inclined to the opinion
that, although we may have enlargement of the body of the
uterus without the cervix being engaged, the cervix is never
enlarged for any length of time without the supra-vaginal
portion of the organ becoming implicated in the disease. I
also believe that not a few of the cases recorded by M.
Huguier were cases of subinvolution of the uterus following
delivery, and not of the condition which I have termed
hypertrophy.

But, in addition to these cases of hypertrophy with elon-
gation of the cervix or of the body of the uterus, or of both,
we meet with cases in which there is no elongation, but the
very reverse. "We sometimes find the cervix shortened,
drawn up, as it were, into the body of the uterus, sometimes
disappearing altogether. In such instances the body of the

23G

DISEASES OF WOMEN.

uterus assumes a globular form. This form of enlargement
gives rise to considerable distress, and it seems specially to
cause intractable irritation of tlio bladder. In one case,
•which was for years occasionally under my observation, this
symptom was the prominent one, and that for which the
patient sought relief.

There is no form of uterine disease in which so little
can be effected by treatment as that to which I am now
referring. If the body of the uterus be engaged, it seems
nearly useless. If, however, we are satisfied that the cervix
only is affected, amputation may be resorted to with advan-
tage; or possibly local depletion and subsequently the re-
peated application of Dr. Greenhalgh’s iodized cotton may
effect some good.

6. It remains for me to allude, and I shall do so very
briefly, to that form of uterine enlargement in which the
organ is stimulated, and increases in size, from the presence of
a fibrous tumour embedded in, or growing from, some portion
of its walls. Cases are recorded in which a fibrous tumour
of very small size, perhaps not larger than a nut, so stimu-
lated the uterus that it increased to five or six time its
normal size, the cavity too being proportionally elongated.
These cases are most perplexing, a post mortem examination
alone being capable of revealing their true nature. For-
tunately they are not of frequent occurrence. In the great
majority of instances a fibrous tumour sooner or later will
bulge into the cavity of the uterus, or project out on the peri-
toneal surface. In either case the tendency of disease is to
render menstruation more profuse ; while in that form of en-
largement depending on hypertrophy of the fibrous tissue of
the uterus, and which is the only form liable to be confounded
with the one now under consideration, menstruation, if inter-
fered with at all, is more likely to be diminished than in-

ENLARGEMENTS OF THE WOMB.

237

creased. The subject of fibrous tumours of the uterus does
not come within the scope of the present lecture. I wish,
however, to draw attention to those cases, of by no means
unfrequent occurrence, where enormous fibrous growths exist
in which the womb is embedded and almost lost. These
cases have over and over again been mistaken for ovarian
tumours, a mistake which the use of the uterine sound should
enable us to avoid. It tells us not only what is the length
of the uterine cavity, but also whether the uterus is free or
embedded in the tumour.

Now, as to diagnosis. I have already stated that the
sound and that alone enables us to decide as to whether the
uterus be enlarged or not, but it affords us no clue as to the
cause of the enlargement. A few general rules, however, if
they do not enable us to give a positive diagnosis, will at
least facilitate materially our decision as to the nature of
any case. Thus, if we meet with an enlarged uterus in a
woman who has aborted or been delivered at the full time,
even though several months have elapsed, the probability is
in favour of the enlargement being dependent on subinvolu-
tion, and this opinion will be confirmed if menorrhagia be
present, as is nearly always the case, at least when the affec-
tion is of recent origin. Again metritis, pelvic cellulitis, or
peritonitis if present or of recent occurrence, are fully suffi-
cient to account for this condition of the uterus, and it should
be always borne in mind that it does not follow that the en-
largement will disappear with the subsidence of the inflam-
mation; in other cases, we should ascertain if menstruation
has been checked or suppressed, and if symptoms referable
to the uterus have followed on this; or if again, pain in the
back and over the pubes was first noticed, menstruation being
subsequently lessened or suppressed. In the former case we
are likely to find that the enlargement depends on conges-

238

DISEASES OF WOMEN.

tion, in the latter on chronic inflammation. It is of no small
importance in deciding on the cause to which enlargement is
due, to note the condition of the menstrual function, for
that will often, in doubtful cases, materially aid our diagnosis;
thus if the enlargement be the result of chronic inflammation,
it will most probably be lessened in quantity; if to subinvo-
lution, the flow will be augmented. Then, again, if there be
menorrhagia in cases of enlarged uterus, unconnected with
any of the causes noticed, we may expect to meet with intra-
uterine polypus, or fibrous tumours, and it will be our duty
to clear up the doubt which exists, by dilating the cervix
and exploring the interior of the uterus.

As 1 have called your attention to the subject of enlarge-
ment of the uterus with the hope that I may aid you in
arriving at a correct diagnosis in cases in which that con-
dition exists, I shall not enter at any length into their treat-
ment ; that of subinvolution was fully discussed on a previous
occasion (Lecture V.), and I must refer you to what was then
said on the subject.

In cases of enlargement following sudden suppression of
menstruation, the administration of saline purgatives, and
subsequently of the bromide and iodide of potassium, con-
jointly in full doses, will generally, if the case be recent, prove
sufficient; bnt should it have been neglected in the early
stages, it will probably pass into the condition of chronic
inflammation, a condition over which medicines possess little
influence. The prolonged use of the perchloride of mercury,
in doses of J^th of a grain three times a day, has been recom-
mended in these cases. I have seen, I think, more benefit
result from local depletion by puncturing the cervix uteri,
than from anything else, and it is a mode of treatment
deserving a fair trial. To be of use it must be repeated fre-
quently at intervals of about five days. The application to

TREATMENT OF ENLARGEMENT.

239

the verge of the anus, of two or three leeches, immediately
after the termination of a menstrual period, where menorr-
hagia is present in connexion with a relaxed and engorged
uterus, also often proves beneficial.

In cases where the uterus has become enlarged and har-
dened, as the result of chronic inflammation, the use of the
waters of Ems or Ivreuznach seems sometimes to have a very
beneficial effect, and if the patient’s means are such as to
admit of her visiting either place, a trial should be made.
As to hypertrophy of the uterus, treatment is seldom likely
to effect good.

In cases of enlargement of the uterus from inflammation
of an acute character, I believe that rest, the exhibition of
opium, and the application of warm poultices over the ab-
domen are the means upon which we should most rely.
Depletion, if practised at all, should be in a limited degree
by a few leeches externally. Mercury I consider to be not
only useless but actually deleterious.

LECTUEE XIII.

Cancer of the Uterus — Pathology of— Varieties met with in the
Uterus — Medullary and Epithelial Cancer Symptoms
Haemorrhage — Pain — Foetid Discharge — Caidijlower Ex-
crescence— Amputation of Cervix — General Treatment .

I propose to-day, gentlemen, to call your attention to the
subject of cancer of the womb; of which disease unfortu-
nately, we have had several examples recently. You must not
suppose that the subject is unimportant because the disease
is, in all probability, not susceptible of cure, for you can
sometimes prolong life, and always alleviate suffering, besides
it is of great importance that you should be capable of
recognizing the existence of cancer and of being able to
pronounce that a disease which may simulate it is not malig-
nant. The idea of cancer is ever present to the minds of
women, and few of them suffer from any chronic ailment, the
symptoms of which are referable to the uterus, without fearing
that they are the subjects of that dreadful disease, and aie suie
to question their medical attendant closely. I need not delay
in pointing out how injurious it would be to your character
were you to pronounce a woman to have cancer, who labouied
under such a comparatively innocent disease as inllammatoiy
hypertrophy of the cervix uteri. Or, how lamentable would
be the consequences, were you to assure your patient that
nothing serious was wrong with her when death was inevit-
able. Yet, both these mistakes are frequently made; mis-
takes for which there is but little excuse.

CANCER OF THE UTERUS.

241

Cancer of the womb is most frequently met with in women,
who have passed, or at least attained, middle age; but this
rule must be received with great reservation. Women under
thirty are not unfrequently attacked with it, and it is impor-
tant that you should bear this in mind, lest, misled by the
youth of your patient, you should give a favourable prog-
nosis in what is really a hopeless case. Still, it is in the
decade between forty and fifty that the greatest proneness to
the disease manifests itself, 50 per cent, of all the cases occur-
ring between these ages. This, you are all aware, coincides
with the period at which what is termed “the change of life”
in woman takes place, when menstruation and the other func-
tions of the reproductive system cease.

There is no disease the symptoms of which are so uncertain
as those which usher in cancer of the uterus ; very frequently,
indeed, it develops itself so insidiously that the patient’s
attention is only attracted to what she supposes to be a very
recent malady, when in reality our first examination proves
the disease to be far advanced towards its fatal termination.
The patient, Mrs. S., in iSTo. 6 Ward, is a striking example of
this fact. She believed herself to have been in good health
up to the 4th of last month, when haemorrhage set in; but
this is impossible, for the entire of the vaginal portion of the
cervix is already destroyed, the uterus is firmly fixed by the
deposit of cancerous matter in the surrounding tissues, and a
gaping opening, surrounded by a jagged, indurated and ulcer-
ated mass, is all that is left of the lower segment of the
uterus. Her end cannot be far distant. Yet it is but a
month since her attention was first attracted to her condition.

Now, gentlemen, I must take it for granted that you all
know something of the pathology of cancer. This is a part
of the subject which I cannot dwell on at any length in a
clinical lecture I shall only say, lest I should Lave any

242

DISEASES OF WOMEN.

lieai'ers who are altogether ignorant of the subject, that this
dreaded disease consists primarily of the deposit, or more
properly of the development, of an abnormal material in
tissues hitherto healthy, and which, consisting in a great
degree of cells of a peculiar formation, has a great tendency
to invade neighbouring structures, and at a later period to
take on a process of destructive ulceration. Dr. West, adopt-
ing the words of Muller, defines cancer to be “those growths
■which destroy the natural structure of all tissues, which
are constitutional from their very commencement, or become
so in the natural process of their development, and which,
when once they have infected the constitution, if extirpated,
invariably return, and conduct the person who is affected by
them, to inevitable destruction.” But, in truth, the 01 igin
of these growths is a puzzle to pathologists. Of the various
forms of cancer, two only are as a rule met with in tho
uterus; namely: —

1st, the Medullary, and

2nd, the Epithelial.

Instances no doubt of true scirrhus, or hard cancer, and
of colloid, or gummy cancer are recorded, but they aie
exceedingly rare, and we may for the present set their consi-
deration aside; the more so as, with the exception of the
greater slowness of progress, there is not any essential diftei-
ence between the course of these two varieties and that of
the medullary form.

As already stated, the first step in the production of the
disease is the growth of the cancerous matter in the substance
of the healthy organ ; and I may here remark that it is in tho
vaginal portion of the cervix uteri that this nearly invariably
occurs. Why this should be is not clear, but such is the fact.
In a few rare instances, however, the body or fundus, is the seat
of the disease. Medullary cancer appears in general first to

CANCER OF THE UTERUS.

213

attack the submucous tissue of the vaginal portion of the
cervix, and subsequently extend to its muscular structure.
Very soon the adjacent parts become implicated. Cancerous-
matter is deposited between the uterus and the bladder an-
teriorly, and the rectum posteriorly, and in consequence
the cervix becomes fixed and immovable. By and by the
mucous membrane at some point gives way, and an ulcerated
surface is formed. The feeling communicated to the finger
by this ulcer is unmistakable. It is hard, irregular, with
sharp edges, and generally bleeds on the slightest touch.
The ulceration extends with considerable rapidity; occa-
sionally, indeed, granulations arise on its surface, and at one
point an attempt may be made at cicatrization; but this soon
gives way, the granulations disappear, and the disease spreads
as before.

When this stage is reached, we generally find a most cha-
racteristic discharge present. It is dark in colour, profuse,
and foetid. Sometimes the foetor is so strong and unmistak-
able that it is possible to diagnose the disease from the
smell alone, even before we make any examination; but this
is not always so. The patient whose case I have alluded to is
an example of this latter condition; for though the disease
is in such an advanced state, she has but little discharge and
that by no means foetid. Haemorrhage, too, if not previously
present, is now nearly sure to occur, and it is very probable
that the decomposition of clots of blood within the uterus
may be one, though not the sole, cause of the foetid charac-
ter of the discharge. The disease is all this time spreading
upwards, and engaging the body of the uterus, and some-
times cancerous masses project into its cavity, while, at the
same time the vagina, also nearly invariably becomes in-
volved. Sometimes, the posterior wall being affected, the
disease extends backwards till the rectum becomes implicated ;

244

' DISEASES OP WOMEN".

but, more commonly, it is the anterior wall which is chiefly
engaged.

When life is prolonged beyond this stage, the ulceration
may destroy not only the muscular structure of the vagina,
but also the adjacent walls of the bladder or rectum, or even
of both. And then to the sufferings previously experienced,
are added the miseries, incidental to vesico- or recto-vaginal
fistula. Under such circumstances death is brought about
by a process of gradual exhaustion; more frequently, how-
ever, the patient sinks at an earlier stage from the effects of
the constantly recurring haemorrhage. The following accu-
rate description of the jiost mortem appearances usually met
with in cases of cancer is given by Mr. H. Arnott, in Vol.
XXI. of the Transactions of the Pathological Society of London :
«It will be noted that in nearly every case the seat of dis-
ease is the same. The os and cervix are more or less com-
pletely destroyed, and the foul ulcer resulting includes the
upper part of the vagina. In more severe cases the floor of
the bladder, is invaded, and perhaps freely perforated, whilst
even the rectum may be opened into the vagina, the uterus
itself being sometimes almost wholly consumed in the general
havoc. In one remarkable case the os and cervix remained,
whilst the whole body of the uterus was destroyed by cancer.”
The pelvic glands are frequently the seat of secondary can-
cerous deposit, while in not a few the ovary and even more
distant organs, including the heart and lungs, become impli-
cated in the disease.

Now, with respect to epithelial cancer, which is the other
form so commonly met with in the uterus. It differs fioin
the medullary in this, that it is generally developed as an
outgrowth, or excrescence from the cervix uteri. In general
it seems first to appear as a tubercle, this increases rapidly,
after a time it becomes fissured, and branches out, so as to

CANCER OF THE UTERUS.

245

form a soft irregular mass, commonly called, from its re-
semblance to the vegetable of that name, “cauliflower ex-
crescence:” a resemblance, however, which is frequently
wanting. The discharge arising from this is very profuse
and watery, but is not generally so foetid as that proceeding
from the medullary form. The growth often attains a con-
siderable size, sometimes forming a mass completely filling
the vagina, and which, from being very vascular, is invaria-
bly accompanied by htemorrhage.

Epithelial cancer occasionally attacks the vagina as a pri-
mary disease. We have had two examples of this recently
in hospital: in one, the superficial ulceration extended to
the very vulva, and the patient sank worn out by pain and
repeated though trifling attacks of hemorrhage. In her case
the entire surface of the vagina was constantly covered with
a dark, pultaceous slough. The other was admitted for
profuse hemorrhage which threatened life. This was found
to proceed from a spot on the anterior wall of the vagina,
not larger than a split pea; it was hard to the touch, and
had a puckered appearance. In a third case, a large mass of
epithelial cancer grew from the posterior part of one labium.
Having thus given you an outline of the course which
cancer usually runs, I must refer to the symptoms it
gives origin to. In the early stages at least they are most
vague and uncertain. To such an extent, indeed, is this the
case, that we not unfrequently meet with instances in which
the entire of the lower portion of the cervix uteri has been
destroyed by the ravages of disease, and yet the existence of
cancer has never for a moment been suspected either by the
sufferer herself or by her friends. The patient to whom I
have already referred affords a well-marked example of this.
She is a married woman, a:t. fifty, has given birth to twelve
children, and has had two miscarriages. Six years ago she

246

DISEASES OF WOMEN.

ceased to menstruate, and was perfectly free from any symp-
tom of uterine disease up to the 6th of last December, when
she noticed a discharge which resembled in all respects natu-
ral menstruation, being red in colour, free from smell, mode-
rate in quantity and not accompanied by pain. The appear-
ance of this discharge did not cause her any anxiety, and she
continued apparently to enjoy her usual good health till three
weeks ago, when (on the 4th January) she was suddenly
attacked writh profuse haemorrhage, which has not as yet
entirely ceased. At no time has there been any foetid dis-
charge, nor did she suffer pain, except a dull back-ache,
apparently the result of debility. But, on making a vaginal
examination, we found the uterus fixed by the deposit of a
large quantity of cancerous matter in the tissues surrounding
the organ, while the lower portion of the cervix was already
destroyed by the process of ulceration, and a wide, gaping,
irregular opening, led up to the body of the uterus. Now,
this case is very instructive — it shows how insidious the dis-
ease may be. Not only is there an extensive deposit of can-
cerous matter, but a considerable portion of the uterus has
been destroyed by ulceration, and yet, till three weeks ago
she presented no symptom of disease, except the slight co-
loured discharge which appeared four weeks previously, and
which she believed to be a return of normal menstruation.
Moreover, it shows that you may have extensive cancerous
ulceration without its being accompanied either by pain,
foetid discharge, or any appearance of cancerous cachexia.
But cases of cancer usually present all these symptoms in a
greater or less degree. You will therefore, be correct in con-
sidering haemorrhage, foetid discharge, pain and cancerous
cachexia as being the symptoms of cancer of the uterus,
though none of them are necessarily present. I shall say a
few words on each.

SYMPTOMS OF CANCER.

247

First, with respect to haemorrhage; it is the most common
and most important of them all; it is also the one which, as
in the present instance, is generally first noticed. If the
patient has not ceased to menstruate, she will probably tell
you that her attention had been attracted by observing the
catamenia to become much more profuse, and to last a longer
time than formerly; then, that the discharge has commenced
to appear irregularly, returning at intervals of a few days,
till finally it is almost continuous. If, on the other hand,
she has passed the “ climacteric” period of life, the first
symptom most probably will be — as was the case with the
patient first alluded to — the sudden appearance of haemorr-
hage, which is occasionally profuse. Sometimes haemorrhage
occurs before any ulceration has taken place ; this is especially
likely if menstruation have not previously ceased ; but it is
after ulceration has occurred that it, as a rule, becomes so
prominent, and often so alarming a symptom. Cases, how-
ever, are met with in which it is not present at all; they are,
however, rare. It may not be an early, or a prominent
symptom, but seldom, indeed, is it altogether wanting. In
general, as the disease advances and the ulceration spreads,
the bleeding becomes more profuse, sometimes in the
form of a continuous draining, more frequently as well-
marked attacks of haemorrhage, occurring at short intervals,
often alarming, and threatening life itself, sometimes even
proving fatal, though much more frequently the patient dies
from the exhaustion consequent on the frequent losses of
blood.

Pain. — Of all the symptoms indicative of cancer, pain is
the most fallacious. Cancer, in its early stage, is, without
doubt, in general a painless disease. This statement is, I
am aware, directly at variance with preconceived notions.
4\omen invariably associate the idea of pain with the ex-

248

DISEASES OF WOMEN.

istenco of cancer, and believe the absence of suffering to be
impossible ; this is, however, a popular error. I have but to
refer to Mrs. S., the patient to whose case I am specially
calling your attention, as a proof of this. Here is a woman
dying of cancer, and yet she is entirely free from pain; I fear,
however, that her prospect of this immunity from suffering
continuing to the last is very doubtful, for as the disease
progresses, pain is seldom absent; frequently, indeed, it be-
comes almost unbearable, so terrible are the paroxysms, so
excruciating the agony. Bear in mind, however, that this
applies to the stage of ulceration only. This absence of pain
forms one of the chief diagnostic marks between chronic in-
flammation of the cervix and cancer in its early stages. When
you meet with a patient who has for a lengthened period
suffered from pain referred to the back, to the uterine and
especially the ovarian regions, shooting down along the inside
of the thigh, and who, on examination, proves to have a
thickened, indurated cervix uteri, the probability is, that this
is due to chronic inflammatory hypertrophy, and not to
malignant disease.

But, as already mentioned, this immunity from suffering
generally ceases after ulceration has taken place; we find,
too, that the attacks of haemorrhage often come on during
severe paroxysms of pain, and seem to relieve them, leading
to the supposition that the pain is due to some form of con-
gestion, for were it not so, the haemorrhage could hardly
bring relief, as undoubtedly it often does. Be this as it
may, the fact remains, that the terrible sufferings in the
second stage of the disease present a marked contrast to the
immunity experienced in the first ; and though there may be
occasional instances in which pain is absent even to the last,
they arc unfortunately rare.

Foetid Discharge. — This, too, is a symptom of variable

CAULIFLOWER EXCRESCENCE.

240

occurrence ; ordinarily .a discharge accompanies the early
stage of malignant uterine disease, but not to an extent
sufficient to alarm the patient; as changes in the cervix
take place, however, and an open cancerous ulcer is formed,
the discharge assumes a different character, it becomes more
profuse, dark-coloured, and foetid. In many instances this
odour is so marked, that without asking a question or making
an examination, the experienced physician can pronounce the
patient to be suffering from malignant disease. Sometimes
the foctor is intolerable, and the profuseuess and acridity of
the discharge so great, as to add materially to the patient’s
suffering by giving rise to painful excoriations. In epithelial
cancer, the discharge is more watery and seldom so foetid as
in the medullary form.

The cases of cauliflower excrescence which have been for
some time past in our ward, differ in many respects from
that of Mrs. S., who affoi’ded us an illustration of the
medullary form. One patient, E. K., aged only twenty-three,
is five years married, but has never been pregnant. She
states that she was quite well till about two months ago,
when menstruation became suddenly profuse; shortly after-
wards she perceived a foetid watery discharge appear in the
intervals between each period. She suffered from severe left
side pain of a paroxysmal character, which became aggravated
before each attack of hcemorrhage, and also from diarrhoea.
On examining her after admission, the whole of the upper
third of the vagina was found to be occupied by a large mass
of epithelial cancer ; the disease had also extended to the
anterior wall of the vagina. Her case was hopeless; we
could but relieve her pain by subcutaneous injections of
morphia, and check the discharge by astringent lotions,
and by the exhibition of gallic acid, acetate of lead, opium,
<fec. She died shortly after.

250

DISEASES OF WOMEN.

Iii another case I at first entertained hopes of being able
to save, or at least to prolong life.

This patient was a young woman, aged twenty-eight,
married, and the mother of a child, who, at the period of her
admission into hospital, was four years old; in the interval
which had elapsed since its birth she had had three miscar-
riages, the last occurring twelve months prior to her admis-
sion. Her health had been very good up to October last,
when she remarked, for the first time, a sanguineous dis-
charge, which appeared in the interval between two regular
menstruation periods. It only lasted three or four days, and
then ceased, but reappeared at irregular intervals during the
next four months, never lasting more than a few days; and
as her general health continued good, she paid no attention
to it. In March last this discharge became more profuse, and
when admitted into the hospital on the 16th of April, she
was in a very anaemic condition. She complained of weak-
ness and of pain in the back, but of nothing else. The dis-
charge, which was very profuse, was of a sanguineous, watery
character, and not very foetid. On making a vaginal examina-
tion, a cancerous mass, about the size of a hen’s egg, was
found, growing mainly from the posterior lip of the os uteri ;
the anterior lip was also engaged, but in a less degree. The
vagina was not implicated in the disease, the uterus was
movable, and on passing the finger upward, the cervix uteri
appeared to be perfectly healthy. I therefore thought it to
be one of those cases in which it would be justifiable to give
the patient a chance of prolonging life by operation, and de-
termined to attempt the amputation of the entire of the cervix
uteri above the diseased portion. This was done accordingly
with the 6crascur. Much difficulty was experienced in
getting the wire round the cervix, the mass being large and
filling up the vagina. However, after some little mauipula-

EPITHELIAL CANCER.

251

tion, I succeeded in encircling the cervix above the growth,
but the moment I attempted to constrict the cervix by
tightening the wire, the apparently healthy tissue yielded,
the wire of the ecraseur became entangled and embedded in
a mass of soft cancer, and I found it impossible to remove
the entire of the cervix. We succeeded, however, in getting
away a large portion, and the stump was then freely
cauterized with strong nitric acid. The patient experienced
no pain subsequently, and she improved greatly after the
operation ; the hemorrhage entirely ceased ; she put up flesh,
and was discharged after a few weeks. I was aware at the
time that this improvement could only be temporary, and I
was not, therefore, surprised when the poor woman again
sought admission, after the lapse of about six months, to find
that she was in a hopeless condition, dying rapidly; she ex-
pired a few days subsequently.

On making a post mortem examination, the body of the
uterus was found to be perfectly healthy. The cavity did
not exhibit the slightest trace of disease ; it was entirely
confined to the lower portion of the cervix, from which the
cancerous mass could be seen growing. The vagina, which
had not been affected when she was first admitted, was also
now engaged.

This case presented four points of interest. First, it
showed at what a very early age this form of cancer may at-
tack the uterus. Secondly, it illustrated the possibility of
hereditary taint, for she stated that her mother and two of
her own sisters had died of uterine cancer. Thirdly, it
showed in what an insidious manner epithelial cancer may
come on. When she was admitted she was in a nearly hope-
less state, and yet believed herself to have been ill but for a
few weeks, and complained only of weakness. Lastly, as to
the operation. It proved how very unpromising it is. How-

DISEASES OF WOMEN.

9^9

ever, this was a case in which it was justifiable, and the
woman’s life was certainly prolonged by it.

In a third case the operation of amputating the cervix
promised very satisfactory results. The patient, a married
woman, aged forty, was sent into hospital for the relief of
what was supposed to be incontinence of urine. Neither the
woman herself, nor the surgeon who had seen her, had any
idea that she was the subject of uterine disease. She was
free from pain, and merely complained of weakness, and of a
constant watery discharge, which saturated her liuen and
which she supposed to be urine. However, on making a
vaginal examination a large mass, evidently a malignant
growth, was found springing from the lips of the os uteri.
On passing the finger beyond this, apparently healthy tissue
could be felt. I therefore determined to remove the whole
cervix without further delay. The cervix was easily encircled
with an iron wire, but so very dense was the tissue to be
divided, that this broke. However, by substituting for it a
strong steel wire I was enabled to divide the cervix. C on-
siderable haemorrhage followed, which w'as restrained by the-
application of the perchloride of iron. This woman made a
rapid recovery, and was discharged a fewr weeks ago, ap-
parently cured, for the whole of the diseased mass was le-
moved; a section of the divided surface examined undei the
microscope exhibiting no trace of cancer cells. This case
was instructive from the almost total absence of s} mptoms.
Our hopes of effecting a permanent cure proved, however, in
this case also, to be fallacious. After the lapse of a jear this
patient presented herself again. She stated that for months
after the operation she had enjoyed good health, but that of
late her abdomen had begun to enlarge, and pain of an intense
character to be always present. On examination the uterus
appeared to be healthy, and nothing definite could be made

AMPUTATION OP CERVIX.

253

out to account for her great sufferings. Her condition, how-
ever, rapidly became worse, and she died within a month in
the greatest agony. On a 'post mortem examination being
made, death was proved to have been due to the growth of
an enormous mass of soft, jelly-like substance, which filled
up the whole of the right inguinal region, and which was
evidently of a malignant character; the uterus was healthy.
Here the disease had without doubt been eradicated from
the uterus, the organ first attacked, but only to reappear,
and in another locality, in different and aggravated form.
Still, by the operation life had been prolonged for quite a
year.

As a commentary on this case, the following extract from
Dr. Graily Hewitt’s work is very appropriate : — “ As a palli-
ative measure frequently, as a curative measure occasionally,
amputation of the cervix uteri (in such cases) is a valuable
operation ; it may possibly prevent a fatal result altogether ;
it will almost certainly postpone that fatal result even when
inevitable. The bleeding and a copious exhaustive discharge
are at once arrested — and for a time the source of danger is
removed.” I can add nothing to this passage ; and though in
cases in which extirpation is out of the question, I shall con-
tinue to use nitric acid or caustic potash as I have hitherto
done; or try the acid nitrate of mercury, as suggested by
Dr. Baker, of New York; or even, perhaps, that rather un-
manageable remedy, bromine, which, according to Dr. Routh,
“ not only arrests the disease locally, but also the cachexia
which accompanies it;” still, where it can be performed, ex-
tirpation is decidedly to be preferred. I use the word extir-
pation advisedly. In the cases just narrated, amputation
of the cervix uteri was the operation performed. But Dr.
Marion Sims has recently introduced a new one, which promises
good results. Instead of amputating the cervix, an opera-

254

DISEASES OF WOMEN.

tion which in many cases fails to remove more than a portion
of the diseased mass, he boldly7- follows the disease right up
into the uterus, removing by means of curette first, and then
by scissors and knife, not only every portion of the diseased
mass, but also the indurated gristly tissue subjacent to it, the
dissection being carried up in some instances beyond the os
internum, necessarily a portion of the uterine wall is also re-
moved. This bold operation is, if carefully performed, quite
safe, doubtless it is very tedious, but the bleeding is not great.
I have performed it twice, but as the patients are still under
treatment I can give no definite opinion as to the final result,
but I believe Dr. Sims when he says, that though cure in cases
of cancer is seldom to be hoped for, from the liability of the
disease to recur in another in the same organ, still that
the operation gives much greater hopes of success than mere
amputation, and that as a matter of fact he has patients
under his observation for two or three years without there
being as yet any recun-ence of the disease.

In order to perform this operation efficiently, it is neces-
sary to procure the knife invented by Dr. Sims for the pur-
pose. My first operation was performed with an ordinary
knife, and it was not satisfactory. I then obtained from M.
Collin, Maison Charriere, Paris, Dr. Sims’ knife ; it is a
beautiful and ingenious instrument, the blade can be fixed at
any angle, and my second operation performed with it was all
that could be desired ; the dissection, which occupied nearly
an hour, reached beyond the os internum ; the large gaping
A shaped cavity which represented the canal of the cervix
was then filled with cotton previously saturated with the
Liq. ferri perchloridi fort, and partially dried. This was left
in situ for some days till it loosened of itself and came away
with the fluid used in syringing the vagina. After it had
been removed, the cavity somewhat contracted by this time.

CANCER OP UTERUS.

255

was again packed with cotton saturated with a strong solu-
tion of the chloride of zinc, and partially dried. This appli-
cation caused, as it always does, much irritation, and some
pain. The cotton was left in the cavity for four days,
and on its removal no further treatment was adopted. The
cavity contracted rapidly, and the present condition of the
patient is promising. I look upon this operation as a most
important improvement in uterine surgery.

I have hitherto spoken of cancer as being a disease of the
cervix uteri, and in the very great majority of instances this
is true ; biit even to this rule there are exceptions, though
they are very rare. The only example of it which has come
to my knowledge, was one brought under the notice of the
Pathological Society by my colleague, Dr. James Little.
Neither the rectum, bladder, vagina, or cervix uteri were
invaded by the disease, but the whole of the body of the
uterus seemed to have been converted into a mass of ence-
phaloid cancer, and yet had a speculum been introduced in
this case, the os would have been found small, and without
any appeai’ance of disease. With respect to such cases as
these I have only to say, that, impotent as we generally are
for good when cancer attacks the cervix, we are utterly
powerless when the disease originates in the body of the
womb.

When speaking of chronic inflammation of the cervix uteri,
I mentioned that the induration which it produces has been
mistaken for that which results from cancer. I think I shall
best enable you to form a correct diagnosis between these two
affections by following the example of Dr. West ( Diseases of
Women, p. 384), and arranging the symptoms of both in a
tabular manner, so that you may the better be able to com-
pare them.

25G

DISEASES OF WOMEN.

In Chronic Inflammation of
Cervix.

The history of the case is
always chronic, often dating-
hack several years.

Pain — always present ; ge-
nerally more severe over left
ovary than elsewhere.

Menstruation scanty and
frequently painful.

Digital examination — Cer-
vix feels hard to the touch,
hut smooth ; pressure with
the finger causes pain.

Uterus — Movable.

Vagina — Not implicated.

In Cancer.

History — Symptoms sel-
dom noticed till within a
comparatively recent period.

Pain — Seldom felt in the
early stages ; most severe in
the hack.

Menstruation — If patient
he young will he increased; if
advanced in life, haemorrhage
may he the first symptom
noticed.

Digital examination — Cer-
vix indurated, uneven and
nodulated ; pressure does not
cause pain.

Uterus — Fixed.

Vagina frequently impli-
cated.

Discharge — Inodorous and Discharge — Generally foetid,

mudo-p urulent.

Having given an outline of the ordinary course which me-
dullary cancer of the uterus follows, and dwelt on its leading
features and symptoms, I must in conclusion allude to the treat-

TREATMENT OF CANCER.

257

ment. Unfortunately we can seldom do more than alleviate
the most prominent symptoms. With the view of deadening
the pain, opium in some shape or form must still be our main
reliance; chloral will often fail, if the sufferings be excessive,
even to produce sleep. Opium is best administered either
per rectum, in the form of suppositories, or by being injected
subcutaneously, commencing with gr. £ or £ of morphia.
No doubt the subcutaneous injection of morphia acts more
rapidly, and its effects last longer than those of opium ad-
ministered in any other manner, while it is, I think, less
deleterious in its after consecpiences. Of astringents ad-
ministered with view of checking the haemorrhage, gallic
acid is, probably, the best. If the bleeding be very severe
you may be compelled to plug the vagina; but, I prefer
in these cases, endeavouring to stop it by the direct applica-
tion to the cervix of a pledget of cotton saturated with a
strong solution of the percliloride of iron in glycerine.

To lessen the foctor of the discharge, you had better add
half an ounce of the solution of the permanganate of potash
to a pint of tepid water, and direct this quantity to be thrown
up the vagina at least twice a day. Another lotion which is
sometimes useful both in allaying the pain and lessening the
discharge, is a solution of nitrate of silver of the strength of
ten grains to the ounce- — two or three ounces of this should
be injected at a time. Of internal remedies, arsenic and iron
are the only ones which will effect any good; indeed I confine
myself nearly altogether to the administration of the latter,
and of its various preparations I prefer either the tincture of
the pcrchloride, or, if the stomach be irritable, the ammonio-
citrato of iron. The diet should of course be nourishing, but
unstimulating. In cases of cauliflower excrescence there is
always the chance, if the case is seen early, of your being
able to prolong life by amputating the cervix, or better still

258

DISEASES OP WOMEN.

by performing Dr. Marion Sims’ operation which I have just
described, or, possibly of destroying the growth by repeated
applications of caustic potash. I effected the latter in the
case of a woman aged nearly sixty; but the disease returned
after the lapse of a few months, and then proved fatal. In-
deed, no matter what treatment be adopted, you should al-
ways let it bo clearly understood that the result is very
doubtful.

LECTUEE XIV.

Ovarian Cystic Disease — Pathology — Unilocular , Multilocular ,
and Dermoid Varieties — Symptoms — Diagnosis.

As I have performed the operation of ovariotomy twice in
our wards within a comparatively recent period, one of the
patients being still in hospital, I do not think it likely that I
shall have a better opportunity than the present of drawing
your attention to the subject of ovarian disease. The affections
to which these organs are liable have, till within the last few
years, been looked upon as almost incurable; but now, as you
are all aware, the extirpation of one or both ovaries 'when in
a state of disease, is performed with great frequency, and
although the result is most uncertain, and though patients
doubtless die from the effects of the operation who might
otherwise live for years, still the number of women whom its
performance has restored to perfect health is so great, that it
steadily increases in professional favour.

The affection to which I shall first direct your attention, is
that known as cystic disease of the ovary, by which term is
understood the development of a cyst, or sac, or of several
cysts, within the ovary, which are filled with a fluid, or semi-
fluid substance produced in their interior. The development
of cysts in the ovary is of very frequent occurrence. They
are met with of all sizes, from that of a pea, to that of a large
sac capable of containing many gallons of fluid. Pathologists

s 2

2G0

DISEASES OF WOMEN.

now agree that the ovarian cyst is in the first instance the
mere dilatation of a Graafian vesicle. This question having
been virtually settled by Rokitansky’s discovery of an
ovule within one of these diseased cysts. As the cyst
grows all trace of its origin is lost, and the sac thus foiined,
becoming distended with fluid, gives origin to the simplest
form of ovarian dropsy, to which, from there being but one
cyst present, the term “unilocular” is applied. But very
generally more than one cyst is developed, several of the
Graafian vesicles becoming simultaneously affected. In the
early stages we may have a cluster of small cysts, none of
them perhaps larger than a currant) then, after a time, one
or two of these seem to take on a condition of active life, and
to become rapidly developed, swelling and increasing, till they
attain a large size, while the others remain stationary or in-
crease slowly. To this aggregation of the cysts, the term
“ multilocular” is applied ; the multilocular tumour is much
more frequently met with than the unilocular.

The contents of these cysts vary in as great a degree as do
their appearance. The unilocular generally contain a light,
straw-coloured fluid, very like serum in chemical qualities.
Sometimes, however, it is turbid and ropy, aud occasionally
seems to contain blood. In the multilocular, the contents of
the cysts even in the same ovary vary much: in some they
are similar to that just described ; iu others, they consist of a
thick gelatinous-looking mass, which is sometimes black and
tenacious. Again, the walls of contiguous cysts, containing
fluids essentially different, may be absorbed under the influ-
ence of pressure, and the contents becoming commingled, we
have then a fluid, partly thick and tenacious, and partly
aqueous. But iu addition to this growth by the amalgamation
of contiguous cysts, there is yet another and very important
process by which these cysts increase, that is, by the develop-

COMPOUND CYSTS.

2G1

mcnt within the parent cyst, of numerous other cysts. These,
according to Dr. Hodgkin, whose observations have been con-
firmed by Sir J. Paget, may be either sessile or pedunculated,
and may cluster in warty-looking masses on the inner surface
of the sac. Thus by the growth of the older cyst, and the
rapid formation of the new, the ovarian tumour sometimes
enlarges with an alarming rapidity, and then the disease
generally proves fatal in a very brief space of time. But
ovarian tumours are seldom made up of these fluid-contain-
ing cysts alone. We nearly invariably also find a consider-
able amount of so-called solid matter present; this solid
matter is produced at the same time as the cyst; sometimes
it is small in quantity, sometimes in bulk it exceeds that of
the fluid containing the cyst, and it may form a tumour of
enormous magnitude.

These partly cystic, partly solid tumours, to which the
term “ compound” is usually attached, are probably the most
common form of ovarian disease. Solid matter exists in them
under various forms. One, which has been described by Mr.
Spencer Wells as being identical in structure with the
adenoid growths found in connection with the mammary
gland, has been called by him Adenoma of the ovary.
Another remarkable one was long looked upon as malignant,
a view now proved to be erroneous; it is termed Alveoldr,
and is likened by Dr. Farre to a sponge, the cells of which
are filled with a jelly-like substance. Other varieties of
solid material are also met with in these cases of compound
ovarian tumours; but it would be impossible for me to enter
with any degree of minuteness into pathological details, for
I desire in these lectures to confine myself as strictly as pos-
sible to the clinical aspect of the diseases of which I treat, and
therefore must refer you to the writings of Paget and Farre,
or to the admirable systematic works of Graily Hewitt, West,

2G2

DISEASES OF WOMEN.

Gaillard Thomas, Barnes, Spencer Wells, and others, for fur-
ther information on the points which I feel compelled to omit.

There is, however, one other variety of ovarian cyst, which
I must notice briefly; namely, that which contains hair, plates
of bone, or fat, and in which even rudimentary teeth have
been found, with or without any fluid being present. These
tumours seldom attain any large size, and may remain indo-
lent for years; on the other hand, they sometimes inflame,
suppurate, and finally may cause death. These dermoid
cysts, as they are termed, are a puzzle to pathologists; the
fact that they sometimes are found in very young children
negatives the idea of their being the product of conception;
while it is equally difficult to admit, as some have suggested,
that they may be the imperfect development of an ovum,
which has been impregnated, but which by some accident
has become enveloped in the tissue of another more advanced
ovum; in truth, however, this matter is as yet a complete
mystery.

Having thus given you a brief outline of the pathology of
ovarian tumours, I shall next call your attention to the con-
sideration of what is of even greater importance to the ob-
stetric surgeon, namely, their symptoms and diagnosis ; the
latter a matter often of the greatest difficulty, an error in
which may entail the most serious consequences, jeopardis-
ing, and even sacrificing life itself.

First, I shall give you a short account of the two cases
recently under treatment here : —

One patient, Margaret M‘D., was unmarried, aged thirty.
She stated that her health had been always good till about
ten weeks previous to her admission, when, on recovering from
a sharp feverish attack, the result of cold, she perceived that
her clothes had become too tight for her, and since then she
increased rapidly in size — so much so as to have become

OVARIOTOMY.

2G3

the object of unjust suspicion; indeed, she subsequently
stated that it was in consequence of the annoyance she ex-
perienced from it being reported that she was pregnant that
she sought medical aid, coming for this purpose from a
remote country district. Her general health was good; she
complained only of thirst and of a frequent desire to mictu-
rate; her appetite was fair, menstruation normal, nutrition
good.

She measured, on admission, 39 inches round the abdo-
men, at the umbilicus; fluctuation was distinct all over the
abdomen, which was dull on percussion anteriorly from the
pubes to about an inch above the umbilicus, but resonant in
both flanks; the uterus was normal in size, shape, and position;
the vagina was narrow, and the hymen perfect. She was
low-spirited and desponding, and while absolutely refusing
to consent to an operation, urged that something should be
done for her. Therefore, with the view of gratifying this
wish, I tapped her on the 6th April, and drew off 256 o-z.
of a dark and somewhat gelatinous fluid. After the tapping
the circumfluence of the abdomen was reduced to 29 inches.
She subsequently suffered no inconvenience, and after a
short stay in hospital was discharged. She returned again
on the 8th June, when the circumfluence of the abdomen
was 35 inches. From that date it continued steadily to
increase till the 12th August, when she expressed her
willingness to undergo any operation which would promise
relief from her intolerable condition. Before the operation
the diagnosis of a unilocular ovarian cyst, with but little
solid matter, was made.

On the morning of the operation she had, at 6 A.M., a
light breakfast, consisting of a cup of tea and a little dry
toast; and at 8 a.m. an egg, beaten up with half an ounce
of brandy, was given. The bowels were freed by means of

2G4

DISEASES OF 'WOMEN'.

an enema, and at 10 a.m. she was placed on the table,
clothed in a flannel jacket, drawers, &c. Ether was the
anaisthetic selected, which was administered by means of
Dr. Richardson’s inhaler, which acted most satisfactorily.
The patient was difficult to narcotise, and, before she was
thoroughly under the influence of the ether, vomited — the
egg, taken quite two hours previously, being rejected undi-
gested— a circumstance which deterred me from giving one
on the next occasion. She vomited also three times during
the progress of the operation, and several times subse-
quently. An incision, not quite five inches in length, was
made in the median line; the cyst was without difficulty
exposed; a sound passed round its surface proved it to be
quite free from adhesions; Spencer Wells’ ti'ocar was then
plunged into it, and the contents evacuated, without one
drop of fluid escaping into the abdomen; the cyst was
drawn out, some little difficulty beiug experienced in ex-
tracting the solid portion, which was of about the size of a
man’s fist; the pedicle was secured by means of Spencer
Wells’ clamp, and after being divided was seared with the
actual cautery; the edges of the incision were then brought
together with carbolised catgut sutures; the abdomen sup-
ported in the usual manner, with broad strips of adhesive
plaster and a flannel roller. The patient was then put to
bed, no anodyne being given, nor any stimulant administered.
The operation occupying, from the commencement of the
incision till the wound was closed, in all about 25 minutes.
At 11 a.m. the pulse was SS. She remained in a state of
semi-unconsciousness till noon, when she woke up and spoke.
Pulse 80. She vomited soon after. To have small pieces
of ice at short intervals, and nothing else. 3 p.m.- — Cathe-
ter passed; stomach sick, with retching subsequently; has
dosed a good deal; to have nothing but ice. 11 p.m. — No

OVARIOTOMY.

2G5-

sickness for some hours; to have a tablespoonful of soda
water and milk iced every fifteen minutes, if not asleep, and
ice ad. lib. She recovered rapidly.

The second case was that of Mrs. M., aged twenty-eight,
married two years; she had given birth to a child just
twelve months previous to admission. Her labour had been
easy, and convalescence good. Was attended by a midwife,
who remarked, after delivery, that the abdomen was larger
than it ought to be. She did not mind this at the time,
but a few weeks subsequently observed that she “was greatly
swelled,” the whole abdomen being uniformly enlarged. A
day or two after this she was attacked with pain in the
right inguinal region. This subsided in four or five days,
but ever after she suffered a good deal of pain at each men-
strual period. These attacks of pain, however, did not
confine her to bed.

From this time she steadily increased in size, the increase
being sometimes so rapid as to be noticeable from day to
day; at other times so gradual as to be almost imperceptible.
Her health continued fairly good. She, however, lost flesh;
but were it not for the weight and inconvenience which her
size caused, would not have sought medical aid.

On admission, though very thin, she was not emaciated;
her health was apparently good, and complexion clear; she
was very cheerful, and, without hesitation, at once expressed
her readiness to undergo the operation of ovariotomy — the
nature and risk of which was clearly explained to her and
her husband.

The circumference of the abdomen was at this time, at
the umbilicus, 34 inches; from umbilicus to right anterior
spinous process measured 9 inches; to left, 91 inches; ensi-
fox-m cartilage to pubes (symphysis), 12 inches. The ab-
dominal walls being very thin, fluctuation was everywhere

26G

DISEASES OF WOMEN.

distinctly perceptible. There was dulness on percussion
over front of abdomen to within 3 inches of ensiform
cartilage; both flanks resonant. The diagnosis of a unilo-
cular ovarian cyst was made.

The operation was performed at 10 a.m., the bowels
having been freed by meaus of an aperient pill taken at
night, and an enema administered in the morning. A light
breakfast of tea and dry toast was given at 6 a.m., and a
little beef tea at 8 o’clock. Ether was the anaesthetic se-
lected, administered by means of Dr. Richardson’s appa-
ratus.

The incision, as in the former case, was commenced
about an inch below the umbilicus, and was in the first
instance about 3| inches in length. The abdominal wall
was so very thin that after the skin had been divided the
greatest care was exercised. The need of this was soon
manifested, for after the dissection had proceeded to but a
limited depth, so thin and attenuated was the abdominal
wall, and so intimately adherent and matted together were
the subjacent structures, that it was impossible to say with
certainty whether the peritoneum was laid open or not;
layer after layer of thin tissue was carefully divided on a
broad director, inserted with much difficulty under each
layer, till at last I ascertained that I was thus dissecting
the actual walls of the cyst itself, the whole anterior surface
of which was intimately and inseparably attached to the
abdominal wall.

Failing to separate the cyst from its attachment to the
abdominal wall below the umbilicus, I enlarged the incision
upwards to within an inch of the ensiform cartilage, hoping
thus to reach the free edge of the cyst, but in vain. All
attempts to separate the adhesions were fruitless, so dense
and intimate were they, and at this juncture, in an effort to

OVARIOTOMY.

267

break them clown forcibly, the cyst ruptured, and the
contents rapidly evacuated through the rent, much of the
fluid escaping into the abdominal cavity. A brief consulta-
tion was now held, and so desperate did the case appear
that one of my colleagues strongly urged the abandonment
of the operation. However, it was decided to make one
more effort. I enlarged the opening into the cyst, and in-
serting my hand into it, reached the bottom, and grasping
the wall at its lowest point, succeeded in inverting the sac,
drawing it through the opening I had made, and finally,
with considerable difficulty, in breaking down from behind
the dense adhesions which had before baffled me, and re-
moving the entire cyst. The pedicle was now secured with
a clamp, and, after being divided, seared with the actual
cautery.

During the tedious and difficult processes described, very
little blood was lost; a large quantity of the contents of the
cyst had, however, escaped into the cavity of the abdomen;
in fact, the pelvis was nearly full of it, and it was necessary
to remove all of this by sponging. This occupied a long
time, but was thoroughly accomplished; no fluid being left
in the abdomen. The wound was then closed, as in the
previous case, by means of catgut ligatures, but in conse-
quence of the escape of the contents of the cyst into the
abdominal cavity, I deemed it wise to insert a drainage tube,
bringing it out above the clamp, its free extremity being
secured by adhesive plaster to the outside of the right thigh
of the patient. The operation lasted one hour and twenty
minutes. The patient vomited three times during the ope-
ration, and twice afterwards.

On being placed in bed there was no appearance of col-
lapse; the pulse was good, about 85; neither stimulant or
opiate was administered, and she was allowed nothing

2G8

DISEASES OF WOMEN'.

■whatever, except ice, for the first eight hours. During the
whole day she was drowsy, dosing a good deal; the catheter
wras passed every fourth hour. 7 .r.M — Pulse, 104; tempe-
rature, 101 '2°; complains of thirst; a good deal of sangui-
neous discharge through the drainage tube ; to have half an
ouuco beef-tea every secoud hour, and ice ad. lib.

I shall not weary you with the details of the subsequent
treatment of these cases, but merely state that her recovery
too was excellent.

Although these two cases had the same favourable termi-
nation, they presented features very markedly different. In
the first the tumour was not only of the simplest kind, but
was free from adhesions, and was removed without the es-
cape of one drop of fluid into the abdomen. In the secoud
case the dense adhesions which existed anteriorly rendered
the removal of the cyst by the ordinary method impossible,
and it was only by inverting the sac, and breaking the adhe-
sions down from behind, that this was finally accomplished.
In consequence of the rupture of the cyst the pelvis Mas
filled with the fluid it had contained, and all this had to
be removed by sponging, a process which occupied a long
time; but notwithstanding these adverse circumstances, the
patient made an excellent and rapid recovery.

In neither of these cases was any drug whatever adminis-
tered, nor wras any stimulant allowed; but, on the other
hand, the greatest care was taken with regard to diet, ice
alone being allowed for the first few hours, aud subsequently
beef-tea and milk in very small quantities and at stated
intervals. To this strict regimen, I believe, much of the
favourable issue of these two cases was due. The greatest
care was also taken to insure the best possible sanitary
conditions, and no person was allowed to enter the ward
subsequent to the operation, except the nurse who had charge

OVARIOTOMY.

2G9

of the case, and two pupils, who, not resident in the hospital,
cave their whole time for the first few days to u atch the

patients.

The general symptoms which usher in ovarian disease, as
you see from the details of the foregoing cases, arc very vague
and uncertain. The patient, may, and indeed probably does,
complain of a considerable amount of discomfort in the o\ a-
rian region, before being conscious of any actual ailment,
but as a rule, the first thing that attracts her attention, is
the discovery of a tumour, or at least a fulness, geneially
in one side of the abdomen, which gradually increases in
size. But often, even when it has reached a considerable
size, the patient does not pay any attention to her state, or
seek medical aid till the disease is far advanced.

In addition to the symptoms enumerated, there are often
various others present referable to pressure on the neighbour-
ing viscera, such as irritation of the bladder, or interference
with defecation; but these are always vague, and valueless
for the purpose of diagnosis. More definite and more im-
portant are the paroxysmal attacks of pain from which the
patient not unfrequently suffers. These may be due to the
tension of some of the folds of the peritoneum, but they are
far more frequently caused by transitory attacks of local
peritonitis, and, as a result, we often find intimate adhesions
formed with the surrounding structures, especially with the
omentum. Such adhesions add greatly to the difficulty, as
well as to the risk, of operations undertaken for the extirpa-
tion of these tumours. In the vast majority of cases, how-
ever, the disease has advanced to a stage, in which either a
well-defined tumour, or distinct fluctuation, or both, exist in
the abdomen, before we ai’e called on to give a diagnosis as
to the nature of the disease from which the patient suffers.
This was so in both the cases recently in this hospital — in

270

DISEASES OF WOJIEX.

both, large tumours existed for a long time prior to their
seeking medical aid.

When this stage has been reached the general health nearly
invariably suffers to a greater or less degree. In the patient
on whose case I am specially commenting, it was merely to
the extent of loss of flesh, while in other’s there is great
emaciation accompanied by dyspnoea, the result of the size
of the tumour, also loss of appetite, and a long train of
secondary symptoms. Menstruation may continue to be
normally performed ; this was so in the patient whose case
we are considering, but in many it becomes irregular as the
disease progresses, or is altogether suppressed. When the
latter occurs, the patient, if she be married, naturally attri-
butes the increased size of the abdomen to pregnane}*, and
even in unmarried women, as happened in the well-known
case of a lady of rank, the unjust suspicion of pregnancy, and
its attendant disgrace, has been attached to the sufferer : an
injustice which the exercise of but a moderate amount of
skill should have prevented.

The leading features of a case of ovarian cystic disease
then, are these : we have a tumour of variable size, the gra-
dual growth of which has generally been traced by the patient.
The surface, in the case of the unilocular tumour, is smooth
and even, while in the multilocular, the separate cysts impart
a lobulated, irregular feel, to the hand passed over the ab-
domen. Fluctuation is generally distiuct in the former, and
can be felt everywhere over the surface. In the latter, this
is only the case here and there, or it may be detected in but
one situation, while we can also nearly invariably make out
at some point, a firm hard mass, indicative of the existence
of solid matter. The whole of the anterior surface of the
abdomen is, in the case of either form of ovarian disease,
dull on percussion, the intestines being forced back behind

OVARIAN DISEASE.

271

the tumour. A vaginal examination, which should be made
in all cases, will prove whether the uterus is of its natural
size and shape ; frequently, however, that organ is displaced,
being drawn upwards and anteflected, but this is far from
being invariably the case.

The conditions or affections with’which cystic disease may
be confounded are numerous. Extra-uterine fcctation, ascites,
especially if complicated with the existence of an enlarged
spleen, tumours of the omentum, and cancerous tumours in
various situations, have been mistaken for ovarian disease j
but errors of diagnosis are specially liable to occur in cases
of fibro-cystic disease of the uterus. Of twenty-three cases
recorded by Mr. Clay, in which ovariotomy had been at-
tempted, but in which the operation was abandoned in con-
sequence of the disease proving not to be ovarian, twelve
were uterine; in two no trace of a tumour whatever could
be found.

While the enlargement of the abdomen from the presence
of an ovarian tumour when menstruation is absent may easily
give rise to the idea of pregnancy, it seems hardly possible
that an impregnated uterus could be mistaken for an ovarian
tumour; yet this mistake has been made, and in order to
guard against the recurrence of a similar error, you should
invariably seek for the usual signs and symptoms of preg-
nancy, some, or all of which, will be sure to be present in a
more or less marked degree. A careful vaginal examination
will prove the uterus itself, and not the ovary, to be the seat
of the enlargement. This is one of those cases in which the
practice of ballotment may possibly be useful; you must,
however, always bear in mind, that pregnancy is not in-
compatible with the existence of disease of at least one
ovary.

The diagnosis between ascites and ovarian dropsy, is not in

272

DISEASES OF WOJIEH.

general difficult. It is with the simple unilocular form that
the question is most likely to arise. The history of the case
often aids us materially in forming our opinion, for the patient
is frequently able to tell you that the swelling commenced
by the gradual enlargement of a small tumour, which, first
felt in one or other iliac region, continued to increase till it
extended across the abdomen, a history which would be in-
compatible with the idea of ascites. In ovarian dropsy also,
there is almost invariably dulness on percussion over the
whole front of the abdomen, the very reverse of this occurs
in ascites, for in that disease the intestines almost invariably
float, and are consequently in contact with the anterior
abdominal wall, therefore percussion yields a resonant sound.
Fluctuation too in ascites is most clearly felt laterally,
in the lumbar regions, that being the point at which it is
likely to be wanting in a case of ovarian dropsy.

I cannot however go further into these details, much less
would it be possible, even if it were desirable, for me to enter
on the consideration of the differential diagnosis between
ovarian cystic disease and that of all the other aflcctions with
which it may possibly be confounded, and I must content
myself with having laid before you the distinctive features
of the former. Your other clinical teachers will explain to
you those of the others, and you must weigh for yourself the
relative value to be assigned to each symptom, when called
upon to decide as to the nature of the affection from which
the patient suffers. But it is essential before passing from
the subject of diagnosis that I should point out to you the
principle distinctive features which exist between ovarian
disease and fibro-cystic degeneration of the uterus; first, be-
cause both diseases are strictly within the limits assigned to
the obstetric surgeon ; and secondly, because the latter is that
which is specially liable to be mistaken for the former, and

DIAGNOSIS OF OVARIAN DISEASE.

273

indeed so closely simulates it as sometimes to mislead the
most careful observer.

I have in a previous lecture given you an outline of the
leading features of fibro-cystic disease of the uterus, and I
think I shall best aid you now, by throwing these into con-
trast with those of ovarian disease, so as to present them to
you in a tabular view; premising, however, that there is not
one of the symptoms enumerated which is not liable to great
variation, and that therefore, the most extreme caution must
be exercised in forming an opinion based on them. I should
also add, that I am now speaking only with reference to tu-
mours of considerable size, and which extend entirely, or very
nearly, across the whole abdomen.

Ovarian Cystic Disease.

May occur at any age, but
probably more frequent be-
fore the age of thirty-six than
after it. Of 281 cases re-
corded by Mr. Clay, and of
which the ages were known,
168 were under thirty-six,
68 of these were aged be-
tween seventeen and twenty-
five years.

Previous history often
throws light on the diagnosis,
a tumour being frequently
felt at first in one or other
iliac region, which gradually
extended across the abdomen.

U terine Fibro-cystic
Disease.

Rarely met with in early
life; of twenty-three cases re-
corded by Mr. Clay, in which
the operation was abandoned
in consequence of the disease
being extra ovarian, thirty-
four was the age of the
youngest patient.

Such a history unlikely to
occur, growth usually more
central.

274

DISEASES OF WOMEN.

Ovarian Cystic Disease.

Growth of tumour, com-
paratively rapid.

Menstruation sometimes
normal, but frequently irre-
gular, and as the disease pro-
gresses is liable to be sup-
pressed; profuse menstrua-
tion of rare occurrence.

Uterus of its normal size,
frequently drawn upwards, so
as to be difficult to reach,
movable, unless bound down
by adhesions and sometimes
anteflected.

Tumour becomes softer as
it increases in size.

Urine voided without diffi-
culty.

Generally health always
suffers more or less, some-
times to a great degree.

Uterine Fibro-cystic
Disease.

Growth, comparatively
slow.

Menstruation profuse, if
tumour be intra-mural or
sub-mucous, normal if sub-
peritoneal.

Uterus elongated if tu-
mour be in its substance or
interior. Sound often pass-
ing for a considerable dis-
tance into its cavity; when
tumour is rotated sound
moves with it.

Time not likely to alter
consistence of tumour.

Difficulty in passing water
occasionally experienced from
pressure on bladder and
urethra.

General health does not
suffer, unless menorrhagia be
present.

If care be taken to weigh each of the distinctive features

FIBRO-CYSTIC DISEASE.

275

here enumerated, the risk of making a serious error in diag-
nosis will.be greatly lessened. Above all, let me impress on
you the necessity of using the uterine sound. It affords
us the most important aid in forming our diagnosis. In the
great majority of cases of large fibroids, whether solid or
fibro cystic, the uterus is either imbedded in, or so firmly
attached to the tumour, that it cannot be moved indepen-
dently of it ; a point which can generally be ascertained, by
inserting the finger into the rectum and keeping it there,
while the sound previously passed into the uterus is rotated
gently. And again the sound should be held steadily, while
an assistant endeavours with both hands, to rotate the tu-
mour itself. These are methods of manipulation which often
enable us to decide whether the uterus is attached to the
tumour or not.

Still even here error is possible; for, if a fibrous tumour
spring from the uterus by a moderately long pedicle, or even
by one as short as that shown in Fig. 21, p. 119, we may be
able to move the uterus to such an extent as to lead to the
conclusion that it is free; and on the other hand it is possible,
that in a case of ovarian disease, the uterus might be so
bound down by adhesions as to be immovable.

Some idea of the difficulty of diagnosing between fibrous
tumours of the uterus when in a state of cystic degeneration,
and ovarian cystic disease, may be gathered from the follow-
ing case, recorded in A olume XII. of the Transactions of the
London Obstetrical Society. The woman was aged thirty-six.
An abdominal tumour had beeii discovered five years pre-
viously, which during the last six months had increased
rapidly. On admission into hospital, a large tumour was
felt which evidently contained no cyst large enough to war-
rant tapping, but which did not feel so hard as a fibrous tu-
mour of the uterus; no vascular murmur was audible, and it

t 2

27G

DISEASES OF WOMEN.

appeared to move quite independently of a uterus of normal
size. When the tumour was exposed, it proved not to bo
ovarian; it sprang from the upper part of the posterior sur-
face of the fundus uteri by a short pedicle. The tumour
was removed, and was found to weigh thirty-four ounces, and
was seventeen inches in diameter. The patient subsequently
died. The fact of the tumour growing almost from the very
fundus of the uterus doubtless permitted that organ to have
a greater amount of mobility than is usually met with in
such cases, and when I add that the operator was Mr. Spencer
Wells, you will agree with me that no means were omitted
by that distinguished surgeon for arriving at a correct opinion
as to the nature of the tumour.

LECTURE XV.

Ovarian Disease ( continued J — Effect of on Duration of Life —
Ovariotomy — Statistics of — Tapping of Cyst — Injection of
Cyst — Congestion and Inflammation of Ovary.

We shall now assume that after having carefully weighed all
the symptoms, you have made up your miud that the case
you have been called to see is one of ovarian disease; it still,
however, remains for you to consider what its probable course
will be, for on this point depends your future treatment.
The most reliable data from which we can form an estimate
as to the probable duration of life in the cases of cystic
disease of the ovary, are those supplied from the tables of
Mr. Stafford Lee. Of 123 cases tabulated by him, nearly a
third died withiu a year, and rather more than one-half
within two years from the date at which the first reliable
symptoms of the disease were noticed, a duration hardly
longer than that of cancer, while but seventeen lived for nine
years or upwards ; of these seventeen, one survived for fifty
years. From these tables we may fairly assume that the
duration of life in cases of the disease under consideration
is unlikely on an average to exceed three or four years. As
a rule, you may consider that the chance of life being pro-
longed, is in an inverse ratio to the rapidity of the growth of
the tumour; for if this be rapid, the patient will speedily be
worn out, and die exhausted no less by the effects of the dis-
ease, than by the distress caused by the size of the tumour

278

DISEASES OF WOMEX*.

itself, even should no intercurrcnt attack carry her off after
a brief illness.

The simple unilocular form seldom becomes dangerous to
life, till the tumour, by its great size, interferes with respira-
tion, and by its pressure impedes the abdominal viscera in
the due performance of their functions. When this stage is
reached, if, with the view of relieving the patient’s sufferings,
we have recourse to tapping, we may actually accelerate the
fatal termination of the case, the drain on the system caused
by the refilling of the sac, increasing the previously existing
exhaustion.

The rupture of a cyst is another possible cause of death;
this seems to be more likely to happen in the multilocular
than in the unilocular tumour, but it certainly is not of very
frequent occurrence; in all these cases there is a great prone-
ness to inflammation of the abdominal, and even of the
thoracic viscera, and an attack which would in others be of
no importance, becomes, when occurring in the patient suffer-
ing from ovarian dropsy, a very serious matter, and therefore
not a few die of diseases not directly connected with the
original malady, but which is not on that account the less
chargeable with the result.

The certain and speedy death, which in the great majority
of cases awaits the sufferer from ovarian disease, has decided
surgeons to attempt its cure by the extirpation of the diseased
organ; the question, then, which in each case has to be decided
is, will the patient if left alone, have a fair chance of being
one of the fortunate twelve who, out of every 100, may be
expected to live for ten years or upwards, or one of the eighty-
eight who, if not operated on, must in a third of that time be
consigned to their graves 1 In deciding on this momentous
question, we should never for one moment lose sight of the
fact, that there are but two possible terminations to opera-

OVARIOTOMY.

27D

tions for the extirpation of ovarian tumours, the one being
perfect recovery, the other speedy death.

The most important element in the calculation undoubtedly
is, the rapidity with which the tumour is increasing in size;
for if this be rapid, the case must soon terminate fatally.
Thus, in one of the cases I am alluding to, the circumference
of the abdomen increased four and a-half inches in one month.
This patient we may say with almost positive certainty, would
have died under any circumstances in a very brief period,
and therefore the operation was called for; but if the increase
be very slow, we should hesitate before sanctioning it. Again,
the state of the patient’s health will materially influence
your judgment; if it be fairly good, and that she seems to
suffer only from the ordinary effects caused by the presence
of a large tumour in the abdomen, she will be in the most
favourable state for the operation. Of course if the patient
be labouring under any other form of organic disease, ovario-
tomy is hardly justifiable ; it would, however, be impossible
to lay down an exact rule on this point.

The presence of firm and extensive adhesions greatly in-
crease the risk of an unfavourable result; when the adhesions
between the surface of the tumour and the surround iug parts
are very intimate the operation is likely to terminate fatally;
but the diagnosis of adhesions is very difficult, in some cases
impossible, to make. By grasping the integuments over the
most prominent parts of the tumour and raising them up,
and by endeavouring by careful manipulation to make them
glide over its surface, a fair estimate may be formed as to
whether they exist anteriorly or not ; but we have no means
of ascertaining what may be the condition of the tumour
posteriorly, and are therefore to a great degree necessarily in
ignorance on this point. The repeated occurrence of attacks
of sharp pain are, however, of importance; if the patient has

280

DISEASES OF WOMEN.

not suffered much from these, extensive adhesions are not
likely to be met with ; but if paroxysms of pain have been
frequently experienced, we may with confidence anticipate
that they have formed.

The simpler the tumour the greater chance there exists of
a favourable termination, and the larger amount of solid ma-
terial the less hopeful is the case. You may take it as a
general rule, that the further the tumour departs from the
true cystic type, the more unfavourable the prognosis becomes.
I am always unwilling to sanction the operation of ovario-
tomy where the tumour is evidently nearly solid.

But even under the most favourable circumstances the
mortality in cases of ovariotomy is great ; in the tables of re-
sults appended to the edition of Kiwisch’s work On Diseases
of the Ovaries, translated by Mr. Clay, of Birmingham, him-
self a successful operator, the results of 537 cases are re-
corded, 212 as successful, and 183 as terminating fatally,
which may be considered as implying that fifty-three per cent.
recovered, and forty-seven per cent, died; but in the large
number of 142 cases the operation had to be abandoned,
either from the adhesions being too intimate to permit of the
tumour being removed, from the disease being discovered to
be extra-ovarian, or from partial excision only having been
effected. Of these, fifty-five died, and this number must, in
order to make the estimate as nearly as possible accurate, be
added to the 183 fatal cases already mentioned. We are
then to deduct from the 537 recorded cases, eighty-seven in
which the operation was commenced but not carried out, but
who nevertheless survived; this leaves 450 to be accounted
for; of these, 212 were perfectly successful, and 238 ter-
minated fatally ; showing that nearly fifty-five per cent, of
the cases operated upon resulted unfavourably.

But though I quote these statistics and have analyzed them

STATISTICS OF OVARIOTOMY.

281

for von, you must not accept them as being a fair index of
the results of the operation at the present time, for the mor-
tality has steadily decreased during the fifteen years which
have elapsed since these tables were published. The errors in
diagnosis are now comparatively few, cases unsuitable for
operation are rejected, while it is becoming rare to hear
of the operation having to be abandoned. Still, making every
allowance for improved diagnosis, and for greater care in the
selection of cases, I do not think we can hope to raise the
percentage of recoveries permanently above sixty-five per
cent. I am aware that a higher estimate than this of the
success of the operation is made by others. Thus, Dr. Graily
Hewitt states that the recoveries are now from sixty-five to
seventy-five per cent. ; perhaps this may be true if errors in
diagnosis be omitted, but this I consider it would be wrong
to do. The results of Mr. Spencer Wells’ fourth series of
one hundred cases of ovariotomy are still more favourable.
Of 100 cases in which the operation was completed, seventy-
eight recovered, twenty-two died, and thirteen other cases in
which the operation was commenced but not completed, or
exploratory incisions only made, seven recovered, and six died.
He shows that the mortality after ovariotomy is in his prac-
tice steadily diminishing; of his first 100 cases, thirty-four
died; of his second 100, twenty-eight died; of his third 100,
twenty-three died; of his fourth 100, twenty-two died. In his
private practice he has of late lost but fourteen per cent.
This is indeed, as it was termed by Dr. West, “a splendid
success ;” still I cannot but feel that no small portion of this
success is due not only to the dexterity of the operator, but
to the skill which he has exhibited in selecting suitable and
rejecting unsuitable cases, a dexterity and skill which all
cannot hope to attain, and I fear that the average of all the
operations undertaken in Great Britain, will still show a con-

282

DISEASES OF WOMEN.

siderably higher mortality than that here recorded. I am
far from wishing to discourage the operation in suitable cases,
and am strongly of opinion that if greater discrimination
in selection be used, if the operation be performed earlier,
and in patients free from symptoms of other diseases, that
the results will be still more favourable, nor do I wish to
overlook the fact, that even if only sixty -five per cent, of our
operations prove successful, we restore to health more than
fifty women out of each 100 cases, who would have died in
about three years, and this, after allowing for the full pro-
portion, who if not treated at all would have lived for a com
paratively long period.

I have hitherto spoken only of excision of the diseased
ovary, an operation which though long known, has only been
extensively practised within the last few years ; but tapping
the cyst has been frequently performed, both as a palliative
measure and also as the first step towards a radical cure.
With the former view it is practised whenever the disten-
sion of the abdomen is so great as to interfere with respira-
tion. Under such circumstances it is always justifiable, but
it is often productive of but very temporary relief, and some-
times only aggravates the patient’s condition, for if the cyst
fills rapidly again, as it generally does, the secretion of such
a large quantity of fluid further weakens the already debili-
tated patient, and moreover tapping is sometimes followed
by the rapid growth of other cysts, which seem to have lain
quiescent previously, their development having been appa-
rently retarded by the pressure exercised on them by the fluid.
Inflammation too may supervene and terminate fatally, and
lastly, bleeding of an alarming character has been known
to occur, occasioned, by the trocar wounding a large vessel.
This may take place either into the cyst or into the abdo-
minal cavity; but even where no accident occurs, alarming

TxVPFING.

283

prostration, and vomiting, have followed on the evacuation
of the cyst, and in not a few cases has fatal peritonitis ensued ;
so that the operation, simple as it is, is not free from danger.
According to Iviwisch, of 130 cases of tapping, twenty-two
died in a few hours or days, twenty-five more died within
six months, and he concludes by stating his conviction,
that all these 130 patients had their lives shortened by the
operation.

There have been cases no doubt recorded in which after
tapping, the cyst has shrivelled up and a permanent cure
resulted, but they have been of such very rare occurrence as
to hold out litttle inducement to us to follow the practice.
Indeed I am not inclined to advise you to perform the opera-
tion of tapping except when compelled to do so as a palliative
measure.

Dr. West advises that the operation of ovariotomy should
not be performed till the cyst has been tapped. I cannot
however concur with him on this point ; but I admit that
when the cyst is emptied and during the process of refilling,
its relations to the surrounding parts can be more readily
made out, and also that the presence or absence of adhe-
sions may perhaps be ascertained. Tapping also informs us
-whether the contents of the cyst be viscid or aqueous,
whether the tumour be unilocular or multilocular, and may
perhaps enable us to decide what amount of solid matter is
present. In obscure cases therefore, it is advisable to tap
for the purpose of aiding us in forming our diagnosis.

When for any reason you decide on tapping an ovarian
cyst, I recommend you to have your patient in bed, and to
let her lie on her right side, the abdomen being brought well
over the edge of the bed. It is advisable to have a bandage
round the patient, as is usual iu tapping for ascites, which is
to be gradually, but not unduly, tightened as the cyst is

284

DISEASES OF WOMEN.

emptied. It is better to use a moderately large trocar. It
is usual also to have an India-rubber tube attached to the
cannula, as suggested by Mr. Spencer Wells, through which
the fluid escapes into a vessel placed to receive it; should
however the contents of the sac be viscid, this adds to the
difficulty of its escape. If the cannula becomes plugged, it
will be necessary to pass a flexible catheter through it for the
purpose of clearing the instrument, a matter sometimes of
some difficulty. After a cyst has been emptied a moderately
tight bandage should be kept round the abdomen and per-
fect rest enjoined for some days.

Tapping, when performed with a view to a radical cure, is
only preliminary to injecting the cyst with some stimulating
fluid — iodine being that usually preferred : the chief objection
to the practice is, that it is only suitable to cases in which
the cyst is single, for if the tumour be multilocular no benefit
is likely to follow. The results are under any circumstances
very uncertain, sometimes none whatever have followed,
while in others the effects were most marked — prostration,
vomiting, and inflammatory symptoms — occasionally result-
ing in a cure of the disease, but sometimes terminating in
death. The operation from its uncertain and sometimes
fatal results is now seldom performed. I have not had any
personal experience of it.

You must have inferred from what I have said that medical
treatment is useless in cases of ovarian dropsy, excepting so
far as the judicious administration of tonics is concerned, and
I trust none of you will ever be guilty of the folly, to use no
harsher expression, of salivating or blistering any patient
you may meet with who is suffering from this disease.

I have hitherto spoken only of cystic disease of the ovaries,
because it is by far the most common as well as most impor-
tant form of disease to which these organs are liable; but

OVARITIS.

285

solid tumours of the ovary are also occasionally met with.
I have never seen an example of this form of disease. Cancer
too may attack these glands. I need hardly add that when
this occurs the case is beyond the reach of treatment.

In addition to these affections which involve change in
structure, the ovary may be attacked by inflammation.
Acute ovaritis is very rare, but chronic inflammation, or at
least congestion of the organ, is common enough. To this
cause we may probably attribute the pain, which in so many
cases is experienced over the seat of the left ovary, and
which is so invariably present in women suffering from
many forms of uterine disease. This pain, which is aggra-
vated at each menstrual period, generally shoots down along
the inside of the thigh; in severe cases nausea is sometimes
complained of, and even vomiting may be present. The left
ovary is the one by far the most frequently engaged ; why
this should be so, I am quite unable to say, but it is a
notable fact which probably you have all observed. Men-
struation is occasionally affected, sometimes becoming scanty
and attended with pain, but on the other hand I am satisfied
that a condition of ovarian irritation short of actual inflam-
mation, but in which there is probably a certain amount of
congestion present, is a not infrequent cause of menorrhagia.
If from the occurrence of the symptoms enumerated you come
to the conclusion that inflammation or congestion of the ovary
exists, you will best relieve that condition by the application
of a few leeches over the seat of the pain, or at the verge of
the anus, by the exhibition of mild cathartics, and of full
doses of the bromides of ammonium or potassium, and sub-
sequently by blistering. We had a good example of chronic
inflammation of the ovary in a young woman recently in the
medical ward, whose prominent symptom was vomiting. I
shall have to refer to her case again; at present I can only

286

DISEASES OF WOMEN.

add that after the application of three or four leeches, the
vomiting, which had been persistent for weeks, was tempo-
rarily checked.

You must not however suppose that every case of pain in
the ovarian region is necessarily due to inflammation; in by
far the majority of these cases it is merely sympathetic, and
is kept up by the existence of some uterine ailment.

Subacute inflammation of the ovary is not of itself likely
to be serious, but the constant pain which the patient suffers
is very wearing, and exposure to cold and many other causes,
may at any time aggravate it, and cause serious symptoms
to arise from the inflammation extending to the peritoneum.
The affection should therefore never be looked upon as
being of no importance.

In many cases of left-side pain depending on ovarian con-
gestion, or irritation, I have found great benefit follow the
inunction twice a day over the affected part, of an ointment
composed of equal parts of the veratria and of the iodide of
potassium ointments, to which, in some cases, I add a
smaller proportion of the unguentum cantharidis.

LECTUEE XYI.

Uterine Therapeutics — External Applications — Hot and Cold
Hip-baths — Use of Chapman's Spinal Hot Water and Ice
Bar/s — Wet Bandages — Blisters — Iodine.

In previous lectures I have called attention to the most pro-
minent features of those forms of uterine disease, which from
time to time we have met with examples of; and in doing
so, I have alluded to the treatment which I considered most
suitable in each case. I think, however, I shall be doing you
some service if I now devote one or two lectures to the con-
sideration in greater detail of what may be termed Uterine
Therapeutics ; a term which I must use in a very extended
sense, so as to include not only medicines administered in-
ternally, but also the medicinal agents employed in the treat-
ment of the diseases we have had under consideration, and
the means by which these remedies should be applied. I
know from my personal experience, that not a few even of
those actually engaged in practice are still so imperfectly ac-
quainted with this subject, that if called upon to give direc-
tions to patients suffering from uterine disease as to the
manner of carrying out the treatment prescribed, they will
either be altogether unable to do so, or will direct its em-
ployment in an inefficient manner.

In considering the subject of the treatment of uterine dis-
ease I shall direct your attention first to applications to
the surface of the body ; secondly, to those made directly
to the vagina, os uteri, or interior of the uterus; and,

288

DISEASES OF WOMEN.

thirdly, to those administered by the mouth or rectum
or by hypodermic injection.

Of external agents, none are of greater value, if judiciously
employed, than baths. I am convinced, however, that much
injury has been done to patients by directing them to use, it
maybe cither hot or cold baths, in a mere empirical fashion,
and without duly weighing the effects they are likely to
produce. I do not now mean to enter into the merits of
sea-bathing, or of the ordinary tepid or hot bath, in which
the whole body is immersed, but only of the cold and warm
hip-bath, which, if judiciously employed, is frequently
specially useful in the treatment of uterine disease.

There exists a very strong popular prejudice in favour of
the various forms of hot baths as a means of inducing men-
struation, if that function be suppressed or imperfectly per-
formed; a prejudice not confined alone to females, but largely
shared, and indeed encouraged, by many medical men.
The common practice adopted in cases where menstruation
is suppressed, or where the discharge if appearing at all is
scanty, is to immerse the feet, legs, and sometimes the pelvis
in warm water, or mustard and water; a practice seldom fol-
lowed by the intended results, but often on the contrary,
proving decidedly injurious. I can confidently advise you
frequently to adopt in such cases a directly opposite line of
treatment; namely, to direct your patient to sit in a bath
containing cold water of a depth sufficient to cover the pelvis,
the legs and feet not being immersed in it, but kept warm, by
being wrapped in flannel, or by being plunged in a foot pan
full of hot water, care being also taken to keep the shoulders
covered. The temperature of the water in the bath, and the
length of time during which the patient should be directed
to sit in it, must vary in each case. The water should not
be too cold. A temperature of about GO0 is probably the best.

USE OF COLD BATHS.

289

The bath should be taken at bedtime, and the patient should
sit in it each night for a period, gradually increased if she
can bear it, of from five to fifteen minutes. In summer ob-
viously it can be borne longer than in winter. On leaving
the bath she should be well rubbed with a coarse towel or
sheet, and put instantly into bed. If chilly, a hot jar should be
applied to the feet; should the patient, however, feel uncom-
fortable or chilly after the bath, either it should not be re-
peated, or the immersion should be for a much shorter time.
Let me point out to you as an example a case recently
treated here in this manner. A. M., set. twenty-five, un-
married, a servant, much confined to the house by her em-
ployment, had of late suffered greatly from headache, pain in
the back, loss of appetite, and constipation. For months
past the menstrual flow had become gradually more and more
scanty, till finally it ceased to appear altogether. There was
not any symptom of constitutional disease, nor of local con-
gestion or inflammation. The bowels being constipated she
was ordered pills containing'aloes in combination with iron.
This sufficed to keep the bowels open, but the headache con-
tinued, and there was not any appearance of a return of the
menstrual discharge. Strychnia was prescribed, still no im-
provement resulted. She was now directed to sit each night
in cold water in the manner described, for ten days before
the date at which the flow was expected, and as a result we
had the satisfaction of finding the catamenia re-appear, very
scantily at first, it is true, but still in sufficient quantity to
afford satisfactory proof that the treatment was telling. The
same course was adopted at the approach of the next men-
strual period, and on that occasion the flow was much more
profuse, and indeed in all respects more nearly normal than
it had been for years, the patient’s general health also im-
proving in a marked degree.

290

DISEASES OF WOMEN.

Bear in mind, however, that the cold hip-bath is not appli-
cable to all cases in which amenorrhcea is a prominent symp-
tom. You should never employ it in any case in which you
have reason to suspect the existence of constitutional disease;
or in patient’s of a very feeble anaemic habit; but if you are
careful in selecting fit cases, I can safely recommend your
imitation of the practice you have seen carried out in the
case I have just drawn your attention to.

The warm hip-bath is a not less valuable agent than the
cold one, and is, moreover, capable of being used with ad-
vantage in a greater variety of cases. You have seen
me repeatedly employ it in the treatment of patients suffer-
ing from endo-metritis. It is also useful in many cases of
dysmenorrhoea as an adjunct to other treatment.

As in the case of the cold hip-bath, I recommend you to
direct the warm bath to be taken at bedtime. The tempera-
ture should not be high, not more than three or four degrees,
above that of the body, care being taken that it does not fall
below that fixed upon during the whole period of immersion,
which should be for about fifteen or twenty minutes. In
cases of endo-metritis, where much pain exists, I am in the
habit of directing these baths to be taken every night for weeks
together, except during the continuance of the menstrual
flow. When, however, they are employed with the view of
relieving painful menstruation, they need only be taken for
eight or ten days preceding the period. In these cases, too,
I find that a somewhat higher temperature (about 105 ) is
needed.

We have yet another mode of employing heat and cold
externally in the treatment of uterine disease; namel \ , by
means of Chapman’s spinal bags. This is a method of very
great value in the employment of these agents, and has be-
sides the advantage of permitting their use without much

VALUE OF SPINAL HOT WATER BAGS.

201

trouble or serious inconvenience to the patient; for while
the bath can only be employed with advantage at bedtime,
the spinal bag can be applied with facility at any hour in the
day, and can be worn, if necessary, when the patient is
dressed.

I have for some years past employed the spinal hot
water bag — 1st, in the treatment of menorrhagia; 2ndly, fyr
the relief of pelvic distress arising in course of uterine or
ovarian disease; 3rdly, in some cases of dysmenorrhoea. I
do not advise you to rely exclusively on the use of the hot
water bag in cases of menorrhagia; or to suspend other
treatment while you employ it, but to use it in conjunction
with such additional remedies as you may deem fit. But
this I can promise you, after very prolonged and careful ob-
servation, that in many cases of profuse menstruation, espe-
cially in patients of relaxed muscular tissue, or in those suf-
fering from the effects of imperfect involution of the uterus
after delivery, you will often succeed in restraining for the
time the excessive loss, by applying to the lumbar vertebras
a 10-inch Chapman’s spinal bag, filled with water at a tem-
perature of about 110° Fahr., and this when other means
have failed. The size I have just named is the best for the
purpose, and the bag should be worn for not less than two
hours at a time. Chapman’s bags are far superior to the
ordinary hot water ones, from the use of which I have not
derived any satisfactory result.

Great benefit also follows the use of the hot water bag in
cases of pain depending on the existence of almost any of the
oidinaiy foims of uterine disease. Few patients labour under
any of these affections without suffering from pain in the back,
above the pubes, over one or other of the ovaries, or along the
margin of the false ribs; and there are indeed few of these
sufferers who do not derive relief from the judicious use of the

u 2

292

DISEASES OF WOMEN.

hot water spinal hag. Indeed, I have often wondered that
it is ordered so rarely. In like manner in cases of dysmen-
orrhcea, especially if they are of inflammatory or congestive
origin, marked relief from present suffering often follows the
wearing of the hot water spinal hag for two hours at a time
at intervals through the day. I say present relief, for I do
nqt think its action exerted any permanent effects on any
of the cases in which I have employed it.

At present there are two cases in the hospital in which I
have practised this treatment. One is that of Mrs. It ;
she has a large intra-mural fibroid, and suffers much from
pain above the pubes shooting down the inside of the thighs;
this is specially severe just before the occurrence of each
menstrual period. Her case is not one favourable for opera-
tion; she has derived the greatest relief from the hot water
spinal bag, and its use has also decidedly lessened the flow
at the catamenial periods, which usually is very profuse.

The other patient, Mrs. D , was admitted last week in a

very anmmic condition. She has been drained by uterine
haemorrhage, which had lasted continuously for three weeks.
So extreme is her debility, that I have not as yet ventured
to dilate the cervix, as is necessary to enable us to ascertain
■with certainty the cause of this dreadful loss; I believe it
will prove to depend on a granular condition of the intra-
uterine mucous membrane. In her case the application of
the hot water bag was at once followed by a diminution of
the discharge, aud time was thus afforded for the remedies
administered internally to act. Previous to its use she had
taken ergot, iron, and quinine in full doses without effect.

The treatment of uterine diseases by the application of
cold to the spine, as best effected by means of Chapman’s
ice bags, requires to be carried out with greater caution than
that by means of the spinal hot water bag. The latter, in-

SPINAL ICE BAGS.

293

judiciously applied, may be altogether useless, or even aggra-
vate suffering, but is not likely to be injurious. The ice bag,
however, may, without doubt, if used in unsuitable cases,
prove decidedly so. I have found the ice bag useful — 1st,
in certain cases of amenorrhoea in which the cold hip-bath
was not suitable ; 2ndly, in relieving the sickness of preg-
nancy; 3rdly, in certain forms of disease in which severe
pelvic and lumbar pains were experienced, together with and
apparently depending on the condition known as spinal irri-
tation.

Some females of feeble constitution are quite unfit for the
prolonged immersion in cold water required for carrying out
the treatment just recommended in certain forms of ame-
norrhoea; in such cases Chapman’s spinal ice bag may often-
times be applied with advantage over the sacrum and lower
lumbar spines. In the first instance it should not be used
for more than fifteen minutes at a time. If well borne its
application should be prolonged; but I consider it better to
carry out this treatment by repeated applications of the ice
bag, made at intervals of some hours, than by prolonged
applications made once or twice a day.

The same observations apply to this mode of treatment
when practised with the view of relieving the pain which,
though referred to the uterus or ovary, appears to depend
on spinal irritation.

Without doubt the application of cold to the spine has
sometimes a marked effect in lessening the distressing sickness
experienced during pi’egnancy. Doubtless, too, it is a remedy
which frequently fails to effect good ; but it is nevertheless
a valuable one; let me, however, urge on you the necessity
of using it with caution, for I am by no means sure that it
is not capable of producing abortion.

There is one other method of relieving the suffering so con-

294

DISEASES OF WOMEN.

stantly experienced in cases of uterine disease by external
means, which it is well to bear in mind, and which I urge on
you not to despise because of its simplicity, or because it is
recommended by a class of men whose practice is not in gene-
ral worthy of imitation. I allude to the wet abdominal
bandage. It is usually applied by dipping one-third of a
calico bandage three yards long and half a yard wide in water;
the wet end is applied around the pelvis and the dry part
rolled outside it so as to prevent the patient’s sheets, or if
worn in the day time, as it can easily be, her clothes, from
being wet. This is specially useful in allaying pains de-
pending on ovarian congestion or irritation, and, indeed, is
beneficial in all cases of uterine disease. My colleague, Dr.
James Little, recommends the use of these bandages for the
relief of habitual constipation, and, it is a mode of treating
this common and most troublesome affection well worthy of
a trial. In such cases you must direct the bandage to be
applied every night for a considerable time.

Blisters are of great value in the treatment of many forms
of uterine disease, especially in cases of chronic metritis or
endo-metritis, where the uterine walls having become thick-
ened and indurated no relief from suffering follows local
blood-letting, whether practised by leeching or puncturing.
In my opinion, blisters prove most useful when applied fre-
quently, at intervals of a few days; they should be of small
size, about the circumference of a" crown piece. I generally
direct them to be placed alternately over the sacrum and
above the pubes, or over the ovary if that be the chief seat
of pain. The application of iodine is in some cases prefer-
able to the use of blisters. It does not weaken the patient
as blisters often do, and should therefore be employed with
patients who may be in a debilitated condition. To produce
any beneficial effects, its use must be continued for many

UTERINE THERAPEUTICS.

295

weeks, and as the repeated application to the same spot
of either the tincture or liniment of iodine, especially the
latter, is apt to produce much irritation, it is best to direct
the iodine to be rubbed in over a limited space only, and
when that spot becomes tender to apply it in a similar way
to an adjoining part, so that without causing the patient
much suffering the treatment may be carried on continuously.
To relieve the distressing backache so commonly present in
these affections, you may sometimes employ with benefit a
liniment composed of ten drachms of the compound camphor
liniment with three of the tincture of aconite and three of
chloroform, or an ointment composed of equal parts of
veratria and iodide of potash ointments. This well rubbed
in over the seat of pain often produces very satisfactory re-
sults. But you will soon discover that all remedies applied
to the surface of the body seldom effect more than transitory
good. To effect a cure, your remedies must be applied directly
to the diseased parts. In my next Lecture I shall call your
attention to these means.

LECTURE XVII.

Uterine Therapeutics ( continued ) — Applications to the Vagina
and Uterus — Vaginal Injections — Intra-uterine Applica-
tions— Medicinal Treatment.

In my last Lecture I directed your attention to those agents
in the treatment of uterine and ovarian disease, which are
found useful when applied to the cutaneous surface of the
body ; to-day I shall speak of that still more important class
which arc applied directly to the vagina and uterus. Of
these, lotions injected into the vagina are the commonest.

Syringing the vagina with water, or with medicated fluids,
is an old and popular remedy for nearly every form of uterine
disease, and is a remedy which though often of great value
if properly performed and pi’actised in suitable cases, is as
often utterly useless, and occasionally positively injurious.
Thus, an elastic enema-bag, capable of holding from six to
ten ounces, is commonly employed for the purpose : such an
instrument is quite unsuitable. But occasionally a worse
because a positively dangerous instrument is employed;
namely, a glass syringe, the end of which is perforated with
five or six holes. Not long since I was requested to see a
woman to whom such a syringe had been supplied. The glass
being thin, the instrument broke in the vagina, and several
pieces of broken glass remained in that canal, causing intense
pain to the patient. By slowly and carefully introducing a
Fergusson’s speculum I was enabled to extract through it the
fragments of the syringe, and no serious consequences happily
followed.

HOT WATER VAGINAL INJECTIONS.

297

Any syringe employed for the purpose of vaginal injec-
tions should be one capable of throwing up a continuous
stream. Such syringes are commonly known as “the sy-
phon syringe,” or “Higginson’s syringe.”

When using the syringe the patient should, if possible, lie
on her back, the hip resting on a bed-pan which receives the
fluid as it escapes from the vagina ; but the majority of
women object to this plan, as it necessitates the presence of
an assistant, and you are then obliged to permit the patient
to inject the fluid from a vessel placed in front of her, or in
a foot-pan or bath over which she sits. This is a very in-
efficient method, for the fluid escapes from the vagina too
rapidly, and does not distend that canal, as it is desirable it
should. In cases where there is not any urgent reason for
the use of medicated lotions, it is often a good plan to direct
the patient to use her syringe while sitting in a warm hip-
bath. I have found this method very efficacious in allaying
vaginal irritation.

But very few patients can continue to use any of the or-
dinary syphon syringes for more than a few minutes at a
time without fatigue ; consequently, where it is our intention
to inject a stream of water into the vagina for a length of
time other means must be adopted.

The use of hot water vaginal injections, of a temperature
of from 98° to 110° according to the nature of the case, are
strongly advocated by Dr. Emmet, of New York; and there is
no doubt but that, when properly administered, they are in
many cases a very efficacious and valuable remedy; but to
carry out this treatment aright four things are necessary : —

1st. The quantity of hot water used on each occasion
should be large;

2nd. The temperature of the water should be kept up to
an even standard;

298

DISEASES OF WOMEN.

3rd. The stream should he continuous;

4th. The patient should lie in such a position as will per-
mit of some of the water to remain in the vagina, and con-
sequently keep that canal more or less distended.

To effect these objects I employ a very simple apparatus
(Fig. 31). * It consists of a tin or zinc vessel, similar to that

Fig. 31.

Apparatus for Vaginal Injections.

used for purposes of irrigation by surgeons, and capable of
holding not less than two gallons. At the side of this can,
near the bottom, an India-rubber tube, six or eight feet in
length, is attached, the free end of which is furnished with a

* Made by Fletcher and Pliillipson, 10 Lower Baggot street, Dublin.

VAGINAL INJECTIONS.

299

stop-cock, and fitted with an ordinary gum-elastic vaginal tube
about a foot in length. The other part of the apparatus con-
sists of a bed-pan, also made of zinc or tin, somewhat simi-
lar in shape to the slipper bed-pan in common use, with an
India-rubber tube affixed to a point near its bottom. The
bed-pan should be at least six inches high in front, sloping
gradually back to about two behind, the posterior third
should be covered in and slightly hollowed, so as to allow
the patient to lie on it without discomfort. In using this
apparatus the patient should lie on a hard couch, or better
still, on a table, upon which a mattress, if necessary, can be
spread. The vessel containing the water should then be
elevated a few feet above the level of the couch on which
the patient lies, which can be done either by placing it on
some article of furniture of sufficient height, or by hanging it
from the wall. The extremity of the tube attached to the
bed-pan being placed in any convenient vessel, the arrange-
ment is complete. Any one can be taught how to regulate
the temperature of the water, and to replenish the vessel
containing it, if that be necessary, while the patient herself
can easily control its flow by means of the stop-cock affixed
to the end of the vaginal tube ; while the tube attached to
the bed-pan carries off the water as it flows into it from the
vagina, and thus obviates the necessity for repeatedly inter-
rupting the douche by having to empty the pan, which
would otherwise arise, thereby also greatly enhancing the
patient’s comfort. The precaution of requiring the patient
when using this arrangement to lie on a hard couch is essen-
tial, for if the pan be placed on anything yielding, the
patient’s weight will sink it below the level of the surface,
and consequently the water will not be carried off by the tube,
but will overflow. Vaginal injections can by this simple and
cheap apparatus, be used with very little trouble.

300

DISEASES OF WOMEN.

Having thus pointed out the method of syringing the va-
gina, it is further important that you should consider the
temperature of the fluid to be injected, the medicinal agents
to be so employed, and their strength.

As a rule, I recommend you not to inject any perfectly
cold fluid into the vagina; doubtless perfectly cold water is
a more tonic application, if I may use that expression, than
warm could be; but the object of injections generally is to
allay irritation, and not to give tone to the vaginal walls ;
that will soon follow as a result if you remove the local affec-
tion. Besides, I have seen very unpleasant and even serious
consequences follow the injection of cold water into the
vagina. Thus severe uterine colic, and intense pain above
the pubes occurred as an immediate result in one case ; and
in another so grave were the symptoms that life was endan-
gered from an attack of pelvic cellulitis which followed the
injection into the vagina of cold water, ordered with the view
of checking profuse menstruation. I recommend you, then,
to direct that the fluid employed be used at about blood
heat, and when vaginitis is present, at even a higher tem-
perature.

The medicinal agents employed for vaginal injections are
very numerous. I, however, restrict myself to a few. I
have so frequently found that solutions of alum and of the sul-
phate of zinc aggravates the patient’s sufferings when vaginitis
was present, that I do not, in such cases, now employ either.
They coagulate the albumen which enters so largely into the
composition of leucorrhoeal discharges, and, if you examine a
patient any time within twenty-four hours after she has used
an alum injection, you will find a number of hard masses in
the vagina, formed by the coagulation of the discharge, which
often cause much discomfort. Borax is a better agent ; but
it, too, sometimes causes irritation, though in a less degree.

VAGINAL INJECTIONS.

301

A drachm of borax to tho pint of water is the strength I
usually direct to be used.

Where the object is to soothe and to allay irritation, an
infusion of tobacco is the best remedy. Tobacco must, how-
ever, be used with caution. Some patients are peculiarly
susceptible to its action ; especially those in whom the orifice
of the vagina being narrow some of the fluid is retained in
the canal. Begin, therefore, by infusing fifteen grains of the
unmanufactured leaf in a pint of boiling water. If this pro-
duces no unpleasant effect increase the strength to thirty, or
even sixty grains, to the pint. In many cases the addition
of a drachm of borax to each pint of the infusion greatly in-
creases the efficacy of the treatment. Many patients, how-
ever, are unable to use the tobacco at all, as even a very
weak infusion causes nausea and faintness. When this is
the case, or where you fear to run the risk of causing any
discomfort to the patient, I recommend you to substitute for
tobacco an infusion of hops, directing an ounce of the latter
to be infused in a pint of boiling water, with or without the
addition of borax, as you may deem advisable.

Cases are, however, frequently met with where no vaginal
inflammation or even irritation exists, but where a profuse
and weakening leucorrhoeal discharge is constantly being
poured out, which it is necessary to check; here astringents,
such as alum or zinc, in the proportion of sixty grains to the
pint of tepid water, often prove most useful. Should they
irritate you will frequently find the decoction of oak bark
serviceable. Warn your patient, however, that the decoction
of oak bark stains linen, for ladies will not be pleased to find
their underclothing or towels covered with ugly stains. This
reminds me to give you a similar caution respecting the use
of the solution of nitrate of silver. A few years ago this was
almost the only remedy employed in the treatment of uterine

302

DISEASES OF WOMEtf.

disease. I can with confidence say that as an application in
cases of disease of the body of the uterus or of the cervix, it
is perfectly useless. In cases of vaginitis it may be employed
with advantage. It must be applied through a speculum,
the surface of the vagina being brushed over with a solution
containing twenty or thirty grains of the salt to an ounce of
water. The application may be repeated at intervals of two
or three days. I now seldom employ the solution of nitrate
of silver, as I look on its use in the majority of cases as a
mistake, and I believe I can obtain better results by other
means.

Of all the agents which are applied to the vagina for the
relief of inflammation or congestion of that canal, glycerine,
without doubt, is one of the most valuable. A small roll of
cotton-wool will absorb five or six drachms of glycerine; you
fasten to this a strong thread or piece of twine, introduce it
through a speculum, and leave it in the vagina for twelve or
even twenty-four hours, directing your patient to withdraw
it at the expiration of that time by means of the string which
is left hanging outside the vulva. Glycerine thus applied
produces a copious watery discharge, which has a marked
effect on the mucous surfaces in immediate contact with it.
Thus, after its application the vagina and vaginal aspect of
the cervix uteri appear pale, and the copious discharge seldom
fails to relieve, for the time at least, that distressing sense
of heat which is complained of in severe cases of vaginitis.
In less acute cases the addition of ten grains of tannic acid
to the ounce of glycerine often proves useful, but if used
before the acute symptoms subside, it may cause increased ir-
ritation. Be sure whenever you use glycerine to warn your
patient that she is to expect a copious discharge, otherwise
the great flow which often comes on almost immediately will
cause much alarm.

INTRA-UTERINE APPLICATIONS.

303

Medicated vaginal pessaries, containing a variety of medi-
cal agents, such as iodide of lead, mercury, tannin, bella-
donna, &c., are in common use. I can only say that I have
never found them of real service, and consequently do not
now employ them. But many drugs may be administered
with great advantage per anum in the shape of suppositories;
this specially holds good with respect to iodoform. In many
painful affections, such as in some cases of fibroid tumours
of the uterus, in which the sufferings are severe, five grains
of iodoform in a suppository introduced into the rectum gives
great relief, and may with advantage be substituted for
opium. It seems to act by relieving muscular spasm.

Numerous medicinal agents are now employed in the
treatment of disease of the cavity of the uterus. These may
be used in the form of fluids, of solids, or of ointments. I
mention them in what I consider to be the order of their
value.

With respect to fluids I give you one caution: do not in-
ject them into the uterus. Such a method is fraught with
great danger, and except that it is generally easy of execu-
tion, possesses no advantage.

The fluids most commonly employed in the treatment of
intra-uterine diseases, are a saturated solution of carbolic
acid, the tincture of the perchloride of iron, tincture of iodine,
the pernitrate of mercury, chromic acid, and the fuming
nitric acid. A solution of nitrate of silver is also sometimes
used, but I believe it to be inefficacious.

Carbolic acid is a mild, but not always a painless applica-
tion; applied to the vaginal surface of the cervix it produces
a very superficial slough, its effects passing off in twenty-four
hours. Applied to the interior of the uterus its effects are
equally superficial and transitory. It is therefore useful in
cases where you desire to apply a mild, stimulating caustic ;

304

DISEASES OF WOMEN.

but it is not suitable when it is necessary to destroy the so-
called granulations which in severe cases cover the vaginal
surface of the cervix and extend into its canal; nor where an

Fig. 32 *

Playfair's Probes.

unhealthy condition of the mucous membrane lining the body
of the uterus, the result of chronic endo-metritis, exists — a
condition which often gives rise to profuse menorrhagia. It
is best applied by means of a flexible silver or copper probe,
such as those suggested by Dr. Playfair (Fig. 32), round
the end of which is wrapped a layer of cotton ; this can be
passed into the uterus to the desired depth. When carried
beyond the os internum the carbolic acid sometimes causes
pain, which, however, soon subsides.

The percliloride of iron is an admirable styptic, and, as
such, should be used when it is desirable to check uterine
haemorrhage. You can apply it in the same manner as the
carbolic acid; but it is generally better to saturate a small roll
of cotton with the tincture (or, as being less irritating, with a
saturated solution of the perchloride in glycerine). Pass this
up through a speculum, and place it in contact with the os
uteri, and then, outside this, another and larger pledget of
cotton well soaked with glycerine. Both these should be re-
moved within twelve hours of their application. I have seen
a very deep slough produced in a case where the cotton,

* Made by Matthews Brothers, 27 Carey-stroet, London.

APPLICATION OF CAUSTICS.

305

saturated with the perchloride, was accidentally left in the
vagina for two days. When it is desirable to check haemorr-
hage depending on a granular condition of the cervix, or the
existence of cancerous ulcerations, the perchloride of iron
is a very valuable agent. Iodine has been used for the
same purpose; it will sometimes answer, but it is less cer-
tain in its effects. The peruitrate of mercury is a powerful
and active caustic. It has been recommended by some
practitioners as an application in cases of malignant disease.
I never employ it, because I believe I have in nitric acid
a caustic equally, if not more efficacious, and one, at the same
time, much safer; for severe salivation has followed the use
of the peruitrate in persons susceptible to the peculiar action
of mercury.

Chromic and nitric acid are nearly identical in their ac-
tion. The former is, however, in my opinion, more uncer-
tain in its effects; it is also more irritating. I therefore
prefer the nitric acid. Its application causes very little, in-
deed, in general, no pain ; it produces but a superficial slough,
and has a wonderful effect in bringing about a healthy con-
dition of the mucous membrane lining the body and cervix
uteri. It also, in many instances, exerts a directly sedative
influence, allaying the severe pain and vesical irritation so
constantly present in cases of endometritis.

No matter which of these fluid caustics you may select
certain rules applicable to all should be borne in mind. In
the first instance, local inflammation, indicated by tender-
ness of the uterus when touched, should, if present, be re-
moved, or at least mitigated, by appropriate treatment before
any of them be used. To effect this the cervix, if soft and
engorged, should be punctured, or if enlarged and indurated,
leeched.

When it is desirable to carry the application up to the

30G

DISEASES OF WOMEN.

fundus, this should, if possible, be done through a cannula or
tube, with the double object of preventing the agent selected
from being weakened by admixture with the secretions dur-
ing its passage through the cervical canal and by contact
with its walls, and also of protecting the healthy structures
from the action of the caustic which may be employed. For
it must be borne in mind that the mucous membrane lining
the cavity of the uterus may be, and often is, diseased, while
that lining the cervical canal is in a perfectly healthy
condition. It is therefore all-important that the healthy
structures should be protected from the action of the caustic.

With the view of effecting this object, I have devised an
instrument of very simple construction. It consists of a
short tube or cannula, made of platinum, and of a curved
stilette, fitting the cannula accurately, which is fixed to a
boxwood handle.

The easiest and most satisfactory method of using this
instrument is by exposing the os uteri by means of a Duck-
bill Speculum, and the cervix being fixed by a tenaculum, to
introduce it into the uterus ; but if you have not an assistant
you will in general succeed in introducing it through a full-
sized Fergusson’s speculum. In either case, when this is
effected the stilette is to be withdrawn, and the cannula
being held steady by means of a pair of long forceps, a cop-
per, or better still, a platinum rod round which a layer of
cotton wool has been carefully rolled, dipped in the agent
selected, is to be passed through the cannula up to the fundus.

Fig. 33.*

Author's Can-nui-a. for Intra-utf.rinf. Medication.

* Manufactured by Fannin and Co., Graf ton-street, Dublin.

APPLICATION OF CAUSTICS.

307

There is seldom much difficulty experienced in introduc-
ing the cannula, for generally in suitable cases the cervical
canal is patulous. If this is not the case a single tent of sea-
tangle, introduced twelve hours before the application is
made, will dilate the cervix sufficiently.

A twofold advantage is gained by employing a cannula
such as I recommend in the treatment of intra-uterine dis-
ease. First, it enables you to convey the caustic up to the
part to which you desire to apply it, without its being weak-
ened by previous contact with the cervical canal. Secondly,
it protects the latter from the action of the caustic, a matter
sometimes of importance if, as is often the case, that canal is
healthy. Should it be desirable to apply the caustic to the
cervical canal, that can be done after the cannula is with-
drawn.

Now one word as to the details of this operation- — if that
be not too dignified a name for the proceeding — for you will
fail in your attempt to carry out this method of cauterizing
the interior of the uterus successfully unless you attend to
various little points. The first is, that you take care to grasp
firmly the little projecting ear of the cannula with a pair of
long forceps before you withdraw the stilette. If you do not
do so, one of two things will happen : either the cannula will
slip out of the cervix, or, if the os be patulous, as is frequently
the case, it will disappear in toto within the cervical canal.
Doubtless it wall soon reappear ; but it is not then always easy
to grasp it, and it will sometimes slip behind the speculum,
or, if grasped, may be found full of mucus. By holding the
cannula firmly wfith the forceps these troubles will be avoided.*

* I have had a vulcanite cannula manufactured for me by the same makers, to
which a handle is attached, and which in this respect resembles that figured in
Dr. Bame3’ recently published work on the Diseases of Women. It is, however, a
clumsier, to my mind, and less handy instrument than the platinum one. It also
is furnished with a stilette to facilitate introduction. But its price is not a third
of that of the'platinum one.

308

DISEASES OF WOMEN.

Next, and even more important, is the fixing of the cotton
firmly on the end of the probe. Draw out the cotton,
moisten the tip of the rod, catch but a few fibres of the cot-
ton at first, and roll the rest slowly and evenly on. This is
better effected by rotating the rod than by rolling the cotton
round it. If these directions be not attended to the cotton
will wrinkle up as it passes through the cannula, and will
render the passage of the rod impossible; or, if loosely put on
may be left behind in the uterus when the rod is withdrawn.
Neither of these accidents will ever occur if the directions I
have given be followed.

These directions apply equally to all liquid caustics used
for the purpose of intra-uterine medication, and the success
of your treatment will depend very much on the dexterity
with which you carry it out. If there be too much cotton
rolled round tbe probe, or if it be loosely rolled on, the rod
will stick in the cannula, and you will have to withdraw it
and re-introduce it; or if you take up too much of the caustic
on the cotton it will trickle down, and may cause a trouble-
some sore in the vagina ; so that to carry out this method,
simple though it be, skill is needed and must be acquired.

Of the solid caustics, the nitrate of silver and sulphate of
zinc are the only ones I use. These can be inserted through
the cannula I have described; but better by means of Sir J.
Simpson’s porte caustique (Fig. 12, p. 74).

By using it you can dispense with the speculum. Ten
grains of the nitrate of silver or of the sulphate of zinc, the
latter in the form'of “zinc points,” as suggested by Dr. Brax-
ton Hicks, may be introduced through it up to the fundus,
and left there to dissolve. Either of these caustics so used
is liable to cause pain, seldom however severe in character;
this too can be, in some degree at least, averted by placing a
pledget of cotton saturated with glycerine in the vagina. I
use both these agents occasionally, but less frequently than

USE OF ACTUAL CAUTERY.

309

formerly, for since I have devised the means of applying the
nitric acid without previous dilatation to the interior of the
uterus by means of the cannula, the results have been so
satisfactory that I now seldom resort to the use of the solid
caustics.

Of the use of ointments I have no personal experience;
they are more difficult to apply than either the fluid or solid
caustics named. Dr. Barnes, however, considers them to be
often of great value in some cases; doubtless they sometimes
are so.

It is occasionally advisable to destroy the tissues of the
cervix to a greater depth than can be effected by means of
nitric acid. For this purpose two agents are employed :
namely, caustic potash, or potassa c. calce, and the actual
cautery; the former is eminently useful in those cases where
the lips of the os uteri is in a state of granular erosion, and
you have seen me use it with the very best results. As I
have in a previous lecture (Lecture IX.) explained the mode
of applying it, I shall not dwell on it now further than to
remind you that it must be used cautiously, and that the
vagina must be protected from the action of the caustic by
the insertion of a pledget of lint saturated with vinegar
under the lower edge of the cervix.

The actual cautery is not much employed in this country,
but in America its use is warmly advocated. Dr. Gaillard
Thomas states that, according to his experience, “ of all the
means of counter-irritation for removing chronic parenchy-
matous congestion, and causing a diminution in the size of
the uterus by stimulating absorption, this is the most effi-
cient and least objectionable as to its consequences.” He
uses a small steel rod terminating in a disc not much larger
than a split pea. This heated in a spirit lamp he applies for
ten or twenty seconds to the cervix, so as to create a small

310

DISEASES OF WOMEN.

slough, re-heating and re-applying the cautery so as to cau-
terize the cervix in two or three places, one at either side of
the os uteri.

Dr. Gctchell, of Philadelphia, also advocates the use of the
actual cautery in cases in which the cervix uteri is hypertro-
phied and indurated; but instead of a steel rod he employs
charcoal sticks, made of nitrate of potash, twenty grains; char-
coal, seven drachms; powdered acacia, one drachm; and water
sufficient to make into a paste. This paste is to be formed
into sticks of any required diameter and length. Dr.
Getchell uses them of about the diameter of the little finger;
the stick is to be held in the flame of a gas or spirit lamp for
a few moments till converted into a live coal, and applied
through a glass or wooden speculum. His directions are :

Take the caustic in the forceps and apply it about four or
five lines from the os to the lip which is most hypertrophied.
Now, if you make slight pressure for a few seconds you will
destroy tissue over a space of about the size of a three cent
piece, and of about two lines in depth ; the pain is very
slight. On withdrawing the cautery I sponge the part with
cold water. I then introduce a pledget of lint saturated with
glycerine, and keep the patient in bed for forty-eight hours.”
The actual cautery may be applied once a month. I have
tried these methods frequently, and can bear testimony to
their efficacy; but I prefer Dr. Getchell’s.

I shall now make a few observations respecting those drugs
which arc most frequently employed in the treatment of uter-
ine disease, premising that medicines have but little influence
on the uterus, aud that therefore, it is not surprising they
effect but comparatively, little good in the chronic diseases
of that organ. My own experience leads me to the conclu-
sion that those which have any direct effect on the uterus do
not exceed four or five in number. I have satisfied myself

ERGOT.

311

that ergot of rye, sulphate of quinine, strychnia, and arsenic
exert a direct action on the uterus. I am not satisfied that
any other medicine does. I do not mean to say that other
medicines are not of use in the treatment of uterine disease,
but I believe that their action is only secondary. Thus, the
administration of iron is often followed by marked benefit in
many cases of old standing uterine disease, but this improve-
ment is only the result of improved general health.

Ergot is a drug which, though long known, lias but recently
been fully recognized. At first used only in labour with the
view of stimulating the muscular fibres of the uterus and ex-
citing them to increased action, it is now prescribed by physi-
cians in cases of haemorrhage from the lungs and other viscera,
sometimes even with very good results in the haemorrhage
occurring from the bowels in typhoid fever ; but it is specially
indicated in nearly all the forms of uterine haemorrhage.
Astringents are, in my opinion, nearly valueless in such cases.
There is hardlv a case of uterine haemorrhage or of menorr-
hagia, unconnected with malignant disease of the uterus, in
which, from one cause or another, that organ is not enlarged,
and its muscular tissue relaxed. Hence the value of ergot ;
it stimulates the muscular fibres of the uterus to contract,
and thus checks the flow of blood. When administered for
this purpose, ergot must be given in large doses and at short
inteiwals. A drachm of the liquid extract, or an ounce of
the infusion should be administered every third hour. In
anaemic patients, the addition of ten drops of the tincture of
the perchloride of iron to each dose greatly enhances the
efficacy of the medicine. Ergot may also be administered
in cases of menorrhagia in the form of powder ; ten grains of
it, directed to be taken at short intervals, being the ordinary
dose.

One other mode of administering ergot deserves special

312

DISEASES OF WOMEN.

notice. I allude to its hypodermic injection. It is thus
employed by physicians in many cases in which ha:morrhage
occurs, unconnected with uterine disease ; but it is specially
useful in the treatment of menorrhagia depending on the
presence of uterine fibroids. The recorded cases seem to prove
that ergotine, that is the active principal of ergot, injected
subcutaneously, not only arrests the profuse haemorrhage
which occurs in connection with these tumours, but has the
effect of diminishing their volume. The drawback to using
it subcutaneously is that it is liable if not carefully used to pro-
duce great irritation at the point where it is injected, the result
frequently being the foi'matiou of troublesome though circum-
scribed abscesses. I generally inject five minims of the Ext.
ergotae liq. B. P., suspended in ten of water, daily, increasing
the strength of the solution to equal parts of Ext. ergot and
water, if it be well borne injecting fifteen or twenty drops of
this each time. In carrying out this treatment, the needle
should be made to penetrate deeply into the muscular struc-
tures.

Next to ergot, quinine is, perhaps, the most valuable agent
at our disposal in the treatment of uterine haemorrhage de-
pending on a relaxed condition of the muscular tissue of the
uterus, such as that which occurs in many cases of subinvo-
lutiou. But you must give it in large doses ; five grains or
upwards every four hours. Instead of sulphuric acid I
generally add ten drops of the tincture of the perchloride of
iron to each dose. I have also found quinine in full doses
efficacious in cases of menorrhagia, where ergot has failed.
Thus I have at present under my care, a lady, whose uterus is
the seat of a subperitoneal fibroid, and she suffers from pro-
fuse menstruation. I have tried in turn every known remedy',
and she finds greater benefit from quinine in seven-grain doses,
with the addition of ten minims of the tincture of the per-

MERCURY.

313

chloride of iron, than from any other drug. She is also one
of those patients who has derived benefit from the use of the
spinal hot water bag. I do not rely as much on quinine in
cases of menorrhagia as I do on ergot, but of this I am satis-
fied, that in some cases in which ergot produced no beneficial
effects, the administration of quinine checked the hemorr-
hage.

One other drug specially deserves notice with reference to
its efficacy in certain forms of menorrhagia. I allude to
arsenic. It seems, by diminishing the calibre of the capillary
arteries, to check the exudation of blood from the inner sur-
face of the uterus. I do not in general administer arsenic
during a menstrual period, but direct it to be taken in the
interval between the periods. I believe it to be of great use
in those cases in which the excessive loss is met with in
females of a leuco-phlegmatic temperament. Arsenic should
be given after meals, in gradually increased doses of from
three to ten drops of the liquor arsenicalis B. P. It is best ad-
ministered in combination with a bitter, such as the compound
tincture of gentian, or, if that be objectionable, with the
compound tincture of chloroform. In several cases I have
found its efficacy increased by the addition of ten drops of
the tincture of digitalis to each dose.

That strychnia exerts a direct action on the uterus is, to
my mind, clearly established. Added to ergot in cases of
parturition, it greatly increases the efficacy of the latter drug,
being specially useful when post partum haemorrhage is anti-
cipated. It appears to have the power of increasing the
tonic contraction of the uterine fibres and of preventing their
undue relaxation when the pain has subsided. Its use is
contra-indicated in all cases where any inflammatory condi-
tion of the uterus or ovary exists. Strychnia is also specially
useful in many forms of ameuoiThoea where it seems desirable

314

DISEASES OF WOMEN.

to stimulate the uterus and ovaries, and in such cases it is
often prescribed with advantage in combination with iron.
It should be administered cautiously, commencing with two
or three drops of the liquor, the doses to be gradually in-
creased to eight, or even ten drops, three times a day. I
have, however, known even small doses produce very unplea-
sant symptoms; some patients being apparently very suscep-
tible of the effects of this drug.

Mercury seems beneficial in some forms of chronic uterine
disease, specially in those in which a low form of chronic in-
flammation exists, with thickening of the uterine wall and
induration. It should be administered in small doses for a
considerable length of time. The only preparation of mer-
cury which I employ in these cases is the perchloride, in doses
of -Jg-th of a grain three times a day. If constipation exists it
may be prescribed in the form of pills, each containing |-th
of the extract of belladonna, with J th or -jth of a grain of
the extract of aloes. I direct these pills to be taken con-
tinuously for many weeks.

Bromide of potassium exerts a marked influence in certain
forms of ovarian irritation and congestion. In many women
the menstrual period is ushered in by severe mammary pains,
the breasts becoming hard and full, pain being also expe-
rienced in the ovarian regions. In such cases thirty grains
of the bromide of potassium, taken three times a day, often
produce marked results. It is also sometimes useful in the
vomiting of pregnancy, but it cannot be relied on. The
same remark applies to its use in the reflex irritation of the
stomach met with in some of the chronic forms of uterine
and ovarian disease.

I may here remark that the hypodermic injection of mor-
phia occasionally controls the vomiting met with in preg-
nancy, or that which sometimes follow severe cases of post

MERCURY.

315

P artum haemorrhage. The formula I now adopt for the solu-
tion to be injected subcutaneously is the following :

Acetatis morphias, gr. viii ;

Liquor, atropiaa, itixlviii;

Glycerini, «lv;

Aquae, ad oiv — M.

Fifteen drops of this solution contain half a grain of the
acetate of morphia, and ^th of a grain of sulphate of
atropia.

Indian hemp is a useful drug, and is often administered
with benefit in cases of painful menstruation. Its use seem
to be specially indicated in those forms of dysmenorrhcea
depending upon the presence of uterine fibroids, in which
the pain experienced at the commencement of the menstrual
periods is sometimes very severe. Most patients bear this
drug well, and derive much benefit from its use. The dose
is from one half to a grain of the extract, or from ten to
fifteen drops of the tincture, every fourth hour ; but with
some it disagrees, producing dizziness and nausea, and in
such its use must be discontinued.

In some patients suffering from uterine disease, great irrita-
bility of the bowels is a prominent symptom.; these patients
are generally in a condition urgently demanding the exhibi-
tion of tonics, which, however, it is difficult to administer,
as they often only increase the previously existing irritation
of the gastro-intestinal mucous membrane. In such cases
you will sometimes succeed by combining quinine with the
carbonate of bismuth, administered in the form of powder ;
two grains of the former with eight or ten of the latter, to
be taken before meals.

Most patients, however, labouring under uterine disease suf-
fer from constipation of the bowels, which is a source of great
discomfort to them, and is also a most troublesome symp-

316

DISEASES OF WOMEN.

tom to treat ; the action of any strong purgative increasing
their sufferings at the time, while the dose must be repeated
at short intervals, often too in augmented doses. In such
cases enemata of cold water, taken regularly at the same hour
daily, frequently answer the purpose of procuring a daily
evacuation. Some patients cannot bear, however, the injec-
tion into the bowels of cold water • when this is the case it
must be used tepid, but its effects are then much less satis-
factory. Over and over again patients have told me that
enemata produced no effect ; on inquiry I found they used
warm water, and on inducing them to try the injection cold,
have known satisfactory results obtained. But many patients
cannot or will not submit to this treatment ; then you may
try a pill containing a quarter of a grain of the extract of
belladonna and four grains of the compound rhubarb pill, to
be taken regularly each night ; or, if iron be indicated, you
may combine the extract of aloes with the sulphate of iron,
in doses of from one quarter of a grain to two grains of the
former, with two grains of the latter, to be taken as a pill
three times a day, before meals. Yery often the smaller
doses named will prove quite sufficient if taken regularly.

But the question of aperients is too extensive a subject for
me to enter into at length. In conclusion, I shall only point
out that in private practice the Pullna and Frederichshall
waters often agree very well. They should be taken before
breakfast, and be warmed by adding a small quantity of hot
water.

END.

DUBLIN: rKINTED BY GUNN AND CAMERON, FLEET STREET.

INDEX.

Abortion, a cause of subin-
volution ....
Absorption of fibroids
Adenoma of the ovary
Allongement of the uterus .
Alveolar tumour of ovary .
Amenorrhcea
congestive
constitutional
treatment of by cold
hip-bath .

by spinal ice bag
Amputation of cervix uteri .
Ansemia ....
Anteflexion of uterus .
Aperients .

Aphtha1, vaginal.

Arbor vita ....
Amott, Mr., on cancer of
the uterus .

Arsenic in menorrhagia
Ascites, diagnosis of, from
ovarian dropsy
Atresia vaginas .

AtthilTs, Dr., intra-uterine
cannula
ecraseur .

Avulsion of fibrous tumours

TAGE

71
14S
261
235
, 261
32
38
. 40

2S8

271

225

220

316

150

244

313

271

306

111

130

Backache, treatment of 291, 295
Bandages, wet abdominal . 294

Barnes’, Dr., dilators . . 90

scissors . . .60

Baths, value of hot and cold 28S
Bennet, Dr., on induration
of cervix .... 172
Bi- valve speculum . . 5

Bladder, reflex irritation of
in cervicitis

in endo-metritis .

in fibrous tumours
in retroflexion
Blisters, use of in uterine
diseases ....
Blood-letting, local . 22,

Borax, vaginal injections
of . ... • 24,

Breasts, reflex irritation of
in retroflexion

Bright’s disease, menorrhagia
in connection with
Bromide of potassium in
uterine therapeutics
Bromine, in cancer of the
womb . . . .

Calcareous transformation
of fibrous tumours .
Cancer of the uterus .

a cause of menorrhagia,
amputation of cervix in
diagnosis of .
discharge in .
epithelial
medullary .
pathology of
j)ost mortem appearances
symptoms of
treatment of
Cancer of the vagina .
Cannabis Inclica, in dysmen-
orrhcea . . . .

Cannula, Dr. Atthill’s intra-
uterine . . . .

rACE

171

187

119

206

294

157

300

206

314

253

148

240
69

225

255

245
244
242

241

244

246

256

245

315

306

INDEX.

FACE

Cannulas, Gooch’s, Dr Att-
hill’s modification of .111
Carbolic acid, intra-uterine
application of . . SO, 303

Catarrh, cervical . .155

Cauliflower excrescence . 245
Caustic potash, application
of ... 103, 173

Caustics, intra-uterine, ap-
plication of . . .184

rules for do. . . 305

Caustics in cancer of the
uterus .... 253
Cautery, actual, use of . 310

Cellulitis, pelvic . . .100

Cervical catarrh . . .155

leucorrhcea . . .27

Cervix uteri, amputation of. 225
dilatation of . . 86

division of . . . 5S

elongation of . . 235

granular ulceration of . S3
hypertrophy of . . 234

induration of . .172

inflammation, acute, of 151
stages of . . . 151

treatment of . . 157

inflammation, chronic, of 170
diagnosis from cancer 256
treatment of . . 173

mode of puncturing . 15S
shortening of . . 235

ulceration of . .153

Chapman’s spinal bags . 290

Charcoal cautery sticks . 310
Children, leucorrhcea in . 26

Chlorosis .... ^44
Chromic acid . . • SOS

Climacteric period, menorr-
hagia at . . • 07, 07

Clitoridectomy . . .30

Cold water, baths, use of . 2SS
encmata . . • 316

Colloid, styptic . . .161

Constipation, due to anaemia 44
to retroflexion . . 204

habitual, treatment of 294, 310

Contracted os . .56

Cotton, iodized . . .174

PAGE

Curette, use of . 95

Cystic disease of ovaries . 259
Cystic polypus . . . 100

Cystocele .... 222
Cysts, development of, in

fibrous tumours . . 147

Cysts, ovarian . . . 259

Depletion, local, of cervix . 1 5S
Dermoid cysts of ovaries . 262
Digital examination of ute-

rus ..... 3

Dilatation of cervix . . 86

Dilators, Dr. Barnes’ . . 90

Dr. Priestly’s . . 56

Displacement of the uterus . 193
Division of cervix . . 5S

Douches, vaginal . . 192

Dropsy, ovarian . . .272

Duck-bill speculum . . 6

Dysmenorrhcea . . .46

cause of pain of . .50

classification of cases of 47

congestive . . .49

depending on endome-
tritis .... 178
mechanical . . .54

neuralgic . . .47

inflammatory . . 50

ovarian . . .49

spasmodic . . .47

Dyspareunia . . .31

Ecrareur, Dr. Atthill’s . Ill
Dr. Hicks’ . . . 10S

Dr. Sims’ . . .110

Electricity in amenorrhcea . 40
Elongation of the cervix uteri 235
Endo-cervicitis . . .155

Endo-metritis . . . 17S

acute do. . . . 1SS

Enemata . . . .316

Enlargements of the uterus 22S
diagnosis of . . . 237

treatment of . . 238

Enucleation of fibrous tu-
mours . . . .129

Epithelial cancer. . . 244

Ergot inuterine therapeutics oil

INDEX.

iii

rAua

Eraot, hypodermic injec-
tions of in fibroids . 131, 312
Examination, bi-manual, of
uterus . - • • 1°

digital do. ... 9

with speculum . . 4

sound . . .10

Expulsion of fibrous tumours 149

Fercvusson’s speculum . 5

Fibrinous polypus . .115

Fibro-cystic disease . 120, 271

Fibrous polypus . . . 104

Fibrous tumours of uterus . 117
absorption of . . 148

avulsion of . . .130

calcareous deposit of . 148

changes in size of . .145

in character of . .148

cysts, development of, in 1 47
detachment of . . 148

effects of on uterus . 236

enucleation of . . 129

ergotine hypodermically
in ... 131

expulsion of . . . 149

extra-uterine . .118

incision of . . 12S

influence of pregnancy
on ... 145

injections in cases of . 130
intra-mural . . . 121

sloughing of . . 148

spontaneous cure of . 148
sub-mucous . . . 121

sub-peritoneal . .120

surgical treatment . 128
Flexions of the uterus . 193

Galvanic stem pessary . 41

Glycerine, in vaginitis . 25, 302

value of, in uterine dis-
eases .... 160
Glycerine of tannic acid in

cervicitis . . .160

Gonorrhrea . . . .22

Gooch’s cannula', Dr. Atthill’s
modification of . . .111

'page

Granular condition of cervix i
of uterus in menorrhagia . S3
in endo-metritis . 186
ulceration of cervix uteri 83
Greenlialgh’s stem pessary . 5S
spring do. . . . 20S

India-rubber plugs . 77

iodized cotton . .174

medicated pessaries . 25

metrotome . . .61

Hematocele, pelvic . .168

Hmmorrliage in cancer uteri 247
in inversion of uterus . 226
in uterine polypi . . 105

Hall’s, Dr., mode of punctur-
ing cervix . 15S

Heart disease, a cause of me-
norrhagia . . . .67

Hepatic do, do, do, 68
Hewitt’s, Dr., speculum . 6

Hicks’, Dr., ecraseur . . 10S

zinc points . . 161, 30S

Hildebrandt, Dr., on hypo-
dermic injection of ergot-
ine ..... 131
Hops, infusion of . . . 301

Hot water, therapeutic uses
of ... 290, 297

Hodge’s, Dr., pessary . . 207

Hymen, imperforate . . 3S

Hypertrophy of cervix . 235
of the uterus. . . 235

causes of . . . 230

diagnosis of . . 237

Hypodermic injection of er-
got . . . . .131

of morphia . . 4S, 315

Ice bags, spinal, in uterine
diseases .... 293
Imperforate hymen . . 3S

Indian hemp in dysmenor-
rhcea .... 315
Induration of cervix uteri . 172
Inflammation of cervix, acute 151
do., chronic . . 170

of uterus, acute . . 1SS

do., chronic . . 190

INDEX.

Injections, hypodermic, of
ergot . . . 131,

of morphia . 166,
intra-uterine, of iodine .

of liq. ferri perchlor.
vaginal . . .24,

Intra-mural fibrous tumours
treatment of
Intra-uterine applica-
tions . . 1S4, 187,

Iodine, injection of, into ova
rian cyst .

into uterine cavity
in uterine diseases
Iodoform

Inversion of uterus
Involution, defective .
Iodized cotton
Iron, perchlor. of, as a styptic
intra-uterine, injection
of, in fibroids .

PAGE

Menorrhagia depending on

PAGE

311

congestion of ovaries and

315

uterus . .

130

on endo-metritis

180

130

on fibrous tumours .

236

306

on granular condition

121

of uterus

126

on hypersemia of ova-

ries

303

of cervix and os

on inversion of uterus

226

2S4

on polypus

105

130

on retention of portion

294

of placenta

303

on retroflexion .

206

226

on subiiivolution

Menstruation

174

interrupted .

304

130

Kkeuznach, waters of, in
chronic inflammation of
uterus .... 239

Lameness, uterine
Laminaria digitata, tents
Leeches, application of,
cervix uteri
Left-side pain
Leucorrhcea
causes of
cervical
due to polypus
infantile
uterine
vaginal

injections in

Mammas, reflex irritation of
Manual examination
Masturbation
Medullary cancer
Menorrhagia

constitutional causes of
local do

depending on cancer

. 200
of 86
to

. 157
. 285
. 17
. 20
. 27
. 106
. 26
. 29
. 18
. 301

rhcea ....
profuse, vide menorrha -
gia .

suppressed, vide amenor-
rhoea ....
suppression of, enlarge-
ment of uterus follow-
ing • •

Mercury in uterine diseases
pemitrate of .

Metritis, chronic.

Metrorrhagia .

Metrotome, Greenhalgh’s .
Dr. Savage’s .

Micturition, frequency of,
vide “ bladder” ._ _ .

Morphia, hypodermic injec-
tion of • 166,

Multilocular ovarian cysts .

231

314

305

190

315

260

204

24-

66
68

247

Nidation . . • .19

Nitrate of silver, solid, use
of in subinvolution . . 74

Nitric acid, application of
to cavity of uterus . 92, 30S

Oakbaek, injection of de-
coction of. 901

(Edema of fibrous tumours . 14o

INDEX.

Ointments, intra-uterine ap-
plication of

Os uteri, vide “ cervix”
contraction of
Ovarian dropsy .

dysmenorrlioea ■
Ovarian tumours, diagnosis
of • • . •

influence of on life
cause of death in .
symptoms of
Ovaries, absence of
adenoma of .
alveolar, tumour of
cystic, disease of .
dermoid, cyst, of .
diagnosis of tumours of
dropsy of the •
inflammation of
Ovariotomy

cases of .

PAGE

309

272

271

277

27S

270

201

259

202

270

271
285
27S
202

Pain, in cancer . . • 247

ovarian . • • 28a

Pelvic, cellulitis . . .164

hematocele . . .168

Peritonitis, a cause of cn-

largement of uterus . . 232

Pessaries, flexible stem . 58

galvanic . . .41

Greenhalgh’s spring . 208
medicated . . .25

Hodge’s, Dr., lever . 207

Phthisis, leucorrhcea in . 20

Pills, purgative . . .316

Placenta, retained, a cause
of menorrhagia . . 96

Placental polypus . .115

Plugging of vagina . .76

Polypus, definition of . .99

cystic or glandular . HO

fibrinous . . .115

fibrous . . .104

mucous . . . 101

placental . . .115

removal of . . .102

symptoms of . . . 105

varieties of . . .100

Porte-caustique, uterine . 74

Potassa fusa, application of
in chronic cervicitis 1 63, 1 1 3
Pregnancy, diagnosis of, from
ovarian tumours
Pregnancy, influence of, on
fibrous tumours .
sickness of, treatment
of . 293, 315

Priestly’s, Dr., dilator .
Prolapsus uteri .

operation for relief of
Pruritus vaginas .

Puncturing cervix, mode of

Quinine in uterine hsemorr

271

145

221

224

158

hage

Rectocele .
Retroflexion of uterus
causes of
diagnosis of .
treatment of .
Retroversion

Savage’s, Dr., metrotome . 59
Scissors, Dr., Barnes’ . . 60

Sea-tangle tents, use of . 87
Simpson’s, Sir James, forte
caustique .

Sickness of pregnancy, spina
ice bags in

Silver, nitrate of, in subinvo
lution

Sound, the uterine
Spinal bags
Speculum, bi-valve
duck-bill
Fergusson’s .

Hewitt’s
introduction of
Sponge-tents

Steel-wire, advantages of, for
ecraseur

Sterility . •

due to .cervical catarrh
Styptic colloid in ulcerations
of cervix . . . •

Strychnia, action of on uterus 314
in ainenorrhcea . 45, 314

312

224

193

197

206

210

293

290

5
7
4

6
7

110

155

162

INDEX.

Strychnia in uterine hiemor-
, rhage . . . . 9S

Subinvolution, causes of . 205
menorrhagia, depending
on . . .70

retroflexion, a sequence
of . . .205

treatment of . 74, 78

Sub-peritoneal fibrous tu-
mour . . . .US

Tannic acid, glycerine of, in
cervicitis. . . . 161

Tapping in ovarian dropsy . 284
Taxis in inversion of uterus . 226
Tents, sea- tangle . . 87

sponge . . .86

Tobacco, infusion of in vagi-
nitis . . . .301

Tumours, fibrous . .117

fibro-cystic . . .120

ovarian . . . 259

urethral . . .27

Ulceration of cervix uteri . 153
styptic colloid in cases of 162
Unilocular ovarian cysts . 260
Urethra, vascular tumour of 27
Uterine diseases, course to be
followed in examination of 9

Uterine lameness. . . 200

leucorrhcea . . .29

porte-caustique . . 74

sound . . . .10

therapeutics . . 2S7

Uterus, absence of . . 35

anteflexion of . . 220

displacements of . .193

enlargements of . .214

exploration of . .91

fibro-cystic, disease of . 120
fibrous tumours of .117

Uterus, granular condition

PAGE

of cavity of .

83,

187

Uterus, hypertrophic

al-

longement of

•

235

hypertrophy of

235

inflammation of, acute .

188

chronic

190

sub-acute

injection of fluids into .

inversion of .

226

involution of

prolapse of .

221

retroflexion of

194

subinvolution of .

•

Vagina, absence of

aphthous condition

of .

atresia of

cancer of

245

closure of

mode of plugging .

shortening of

Vaginal injections

24,

294

Vaginismus

Vaginitis, acute .

sub-acute

Vomiting, due to masturba-
tion . . . . .29

to retroflexion . . 204

checked by morphia
hypodermically 166, 292
by cold to spine . . 293

Water, cold, therapeutic
uses of . . 288, 293, 294

hot, do., do. . 2S8, 292
application of to spine 292
vaginal injections of . 297

Whites, the . . .17

Zinc points, Dr. Hicks’ 161, 308
injections . . . 300

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